David May: Thank you. We now have a few housekeeping items to address before we start: Your phones will stay in listen-only mode during the entire webcast. However, listeners can send questions throughout this event. Our moderator will ask as many as possible before the hour is up. You can find the questions window on the right-hand side of your screen connected to the webcast dashboard that appeared when you first joined the call. A recording of today's discussion will be available on our website, ModernHealthcare.com/webcast. Within a few days, all attendees will receive a follow-up email, including a link to that recording. Slides used during today's presentations will also be available online. And now, I'd like to turn the webcast over to Joseph Conn, a Modern Healthcare reporter and the moderator for today's webcast. He will introduce our panelists. Joe.
Joseph Conn: Thank you and welcome to our webcast ‘Making the Connection.' For the next hour, we will hear from three outstanding health IT leaders who not surprisingly do their leading at three outstanding healthcare organizations. They are themselves leaders in the use of health information technology. Our distinguished guests are: Dr. Steve Heilman, associate vice president and chief medical information officer at Louisville-based Norton Healthcare. With five hospitals and nearly 60 practice locations, Norton is the largest healthcare system in the great state of Kentucky. Welcome, Steve. Also with us today is Jim Younkin, director of information technology at the Geisinger Health System in Danville, Pa. Jim also wears a couple of IT community hats. He's director of the Keystone Health Information Exchange, which covers 31 counties in the central and northeastern parts of Pennsylvania. And Jim is the administrator of the Keystone Beacon Community, one of 17 pilot programs funded through the Office of the National Coordinator for Health Information Technology and funded by the American Recovery and Reinvestment Act. Welcome, Jim. Rounding out our panel is Dave Muntz, the chief information officer at Baylor Health System of Dallas, which is home to as we will soon find out not only the Baylor Quality Alliance but also a fairly solid basketball team. I'm a Chicago Bulls fan, and I was rooting for the Mavs to avenge us over Miami, and they did. We'll find out what Baylor is up to with its IT extension plans as well. And Dave, welcome. The questions we hope to answer in this webcast are: What are the IT systems strategies that forward-thinking provider organizations are using to connect the disparate components of their delivery networks to share clinical and financial information? So let's get started on hearing some answers. We'll ask our speakers to each make 10-minute presentations then see if our panelists have any questions for one another, and then we'll open up the meeting to questions from our audience. Steve, let's start with you.
Steven Heilman: Thank you, Joe, and good morning everyone. My name is Dr. Steve Heilman. I'm the chief medical information officer for Norton Healthcare. I'm a board-certified emergency physician and I've been practicing emergency medicine for the last nine years. I've served as the CMIO for the last three for Norton Healthcare. I just want to give a little background about Norton: We are an integrated delivery network. We have five not-for-profit hospitals, 14 outpatient centers, all located in Louisville, Ky. We have about 1.4 million yearly patient encounters, about $1.5 billion in yearly revenue. We employ 11,000 people. Of those, we have 450 employed physicians and over 2,000 physicians on our medical staff currently. We do have 2,000 licensed beds, and we see about 60,000 admissions per year. Next slide, please.
So, part of what we're talking today is about alternative forms of payment and payment reform, and I recall this for our journey for accountable care is kind of where we're headed. Since 2005, Norton has taken a very strong stance on being transparent to the community. Back in 2005, we started to publish over 600 of our nationally recognized quality core metrics and indicators and best practices on our website. And at the time the medical staff—I will say that we were not top performers. We had a lot of red on our red-green report, but it was that kind of transparency and the willingness of our board and our executive team to say, ‘We realize we're not doing a great job at this, but we're going to publish it, and we expect your help to help make those things better. We will give you the performance improvement initiatives and support you need to redefine your processes, but we need to provide better-quality care.' And, over time, working with the physicians, the medical staff and the nurses, Norton really did transform, and it was a great honor this year—we actually won the National Quality Forum award based a lot on what we've done with publishing those metrics and how we went about correcting them and where we had room for improvement. In the last two years, we have joined with another company here in Louisville, Humana, which is based here as well, and we applied for one of the commercial ACO pilots with the Dartmouth and Brookings Institute. And it's been a good learning session for us to try to come into an ACO from a commercial standpoint to try to figure out what would work in that field as opposed to how we're trying to look at things while working with CMS as well. As I say, our initial partner is Humana. We do have future plans to involve other managed-care providers. And our initial ACO group has basically Norton Healthcare employees and Humana employees who use Norton physicians. And from that population, we have about 10,000 lives covered in our ACO. There's about 300 physicians that we have and we've been following that. We have—the first year of data has come back on our ACO, and some of the metrics that we're looking at. And we've made progress, but, you know, a lot of the ACO development in the commercial environment is learning as you go, and we've learned a lot of lessons from it. And we hope to take those forward as we start looking at how to do things with CMS as well. Next slide, please.
One thing we have learned is moving forward in the future everything is going to be based on data. It's really going to be on what data can you present to the payers, to the patients, to the providers? How do you communicate all that information back and forth between everyone to make sure we're providing the best quality of care that we can give to our patients? You know, everything we've done in terms of our quality metrics we've pretty much done on a paper world. We've done chart review and data extraction. When we had room for improvement, we put in extra sheets of paper that made us document why there were exclusions as to why we were not doing a certain practice that we considered best practices. And by those things we were able to capture a lot more information. But going forward, everyone realizes we need to get to the next world to get rid of paper and get on electronic medical records. So with that we have partnered with Epic, and we're currently deploying fully integrated medical record across all of our practices and all of our hospitals. It's really good timing for us based on everything that's going on with the HITECH Act, but also knowing that ICD-10 transitions are coming, we're basically redoing all of our revenue cycle and educating all of our physicians and staff on improved documentation. So while I don't think—it's not my recommendation to tear out your HIS system and start all new in order to get everybody to be ICD-10 compliant, I just think we really have good timing in this. We're being able to revamp our complete system with one fell swoop as we install an all new HIS. Having also providing us the opportunity to participate in information exchanges, we have not jumped right in as much as some of the other people on this call will be able to talk about. We're still waiting to see on business models how they develop over time and sustainability after government funding kind of goes away. But we're starting to explore how to get information out more with other payers and other providers in our community. We also feel that by putting in the electronic medical record, we'll be able to standardize best practices within our institution as well and then provide more clinical decision support, which will ultimately take our quality of care to the next level. A lot of things have been done in sort of silos, and I think as you standardize that care that you can do with an electronic medical record, you'll see great improvements in the quality that you can provide. Additionally, we've partnered with Microsoft Amalga to develop an enterprise data warehouse. We feel like this sort of tool allows us to take different data points from just disparate systems and combine them into one place so that all of our providers, and our executives can basically use the data warehouse to combine costs and accounting data with clinical data, with patient-satisfaction data, with payer data, and get a better view of the continuum of care of a patient and use those tools to help figure out where we have opportunities for improvement. Over time, be able to develop patient registries within our data warehouse and then actually start using some predictive population management tools to see: How can we affect readmissions? How can we take better care of certain registries of diabetic patients or heart-failure patients or asthma patients? I think that's the power in continuing to develop those tools. Next slide, please.
And really what's going on now is we've done well on quality, and I think now when you start looking at accountable care organizations, it's really a change from quality to value is really what people want to start looking at. How can you provide the highest quality of care at the greatest value? And you really have to start looking at what you're spending and does that make sense? Part of what we've done is really developed executive dashboards and physician dashboards using different tools that really show users and practitioners how much they're spending to provide care, their length of stay, trying to give that in as close to real-time as possible so that they impact the care they're providing, and that will change their behaviors if they see a negative compared to how everybody else is practicing within the organization. We're doing active engagement with our patients. I think in part of accountable care, it really is not just the payer and provider but it's patients taking accountability for the care that they're receiving. We're continually trying to do clinical re-engineering and develop interventions so that if we do identify opportunities for improvement, we have developed downstream effects that will help improve the care that we provide, in fact, a clinical decision-support standardization to make sure we're all doing the best practices. Next slide, please.
And, just to kind of sum up, this is before we dug all of our IT infrastructure overhaul. One of the things we did with our ACO and some of the other agenda items that we've been looking at, is we managed how we take care of our patients by utilizing our hospitals differently. And this slide's just to give you effect of basically saying most of our surgeons now use our hospitalists as the primary [unclear: 11:32] and it's part of our clinical effectiveness module. And looking at one hospitalist group back in 2008 to 2009, they admitted 1,000 people. In 2010 to 2011, they're now admitting 6,000 people. Obviously we employ more providers to do that, but the key point of this slide is that they were able to actually cut down 30-day readmissions for any diagnosis, cut down 30-day readmissions for same diagnosis by half, decrease our length of stay by more than a day, and basically cut down on consultants used, which overall has affected the cost of care that we provide. And I think if you start looking forward, value-based purchasing and bundled payments, I think these are the steps that are going to be effective. And then when you start adding in all the technology, infrastructure, you'll see great improvements in the care that you provide. With that, I'm going to pass it on back to Joe.
Joseph Conn: Thanks, doc. Well, Jim, you're up. So I'll let you get started.
Jim Younkin: Well, good morning everyone. I am the director of information technology here with Geisinger Health System. I've been here for about the last seven years and seen a lot of growth in the area of information technology, although Geisinger has been using electronic health records since 1996 with the installation of the Epic system and is now in use in all 40-plus clinics that we have in the ambulatory setting as well as all of our acute-care hospitals. We have two acute-care hospitals—a children's hospital, heart center and cancer center. We employ over 800 physicians in primary and specialty care, a number of those are hospital-based, but also provide care in those community practice sites. We also have a health plan as part of our system that's over 272,000 covered lives, so it enabled us to do a lot of things. Today I want to talk to you about the Beacon Community Initiative, which I have been administering, and in April 2010, we received funding from the Office of the National Coordinator for Health IT as one of 17 selected communities throughout the U.S. that have already made inroads in development of secure, private and accurate systems of electronic health record adoption and health information exchange. The 17 Beacon Communities focus statistics on measurable improvement goals in three areas for health system improvement: quality, cost efficiency and population health to demonstrate the ability to get health IT to transform local healthcare systems. The Keystone Beacon Community, specifically which is led by Geisinger, the network of doctors, nurses, hospitals, nursing homes and other healthcare professionals that are working together to give patients the best and most convenient care in Central Pennsylvania. You can see the location there of the five counties. We have four participating hospitals and more than 200 primary-care and specialty physicians that are focused on improving the continuity, quality and efficiency of care for patients with chronic obstructive pulmonary disease and congestive heart failure, paying particular attention to opportunities that we may incur to prevent unnecessary or repeat hospitalization. Most of you are familiar with statistics that nearly one-fifth of Medicare patients discharged from the hospital are readmitted within 30 days. Many of those re-hospitalizations can be prevented by helping patients better understand their discharge instructions, their follow-up care and among those conditions with the highest rates of re-hospitalizations are CHS, COPD and surgical procedures. The additional care is very expensive, so by reducing those readmissions, we believe that we can also reduce the cost of delivering the care. We connect healthcare providers in Central Pennsylvania through a secure electronic communication channel to share our patients medical information, provide better care coordination, improve healthcare quality and reduce those costs. The Keystone Beacon Community was built using the existing IT infrastructure that Geisinger had in place, both the electronic health record and the Keystone health information exchange. Next slide, please.
So the specific objective of our group are to reduce those preventable hospital admissions—readmissions—and emergency visits also to provide private and secure access to patient information when and where it's needed, improve the patient's ability to care for themselves and avoid complications through better communications with their doctors and nurses and increase the use of evidence-based standards of care, and provide educational materials to help the patient better understand how to improve their health. There's three main pillars to our approach—the first is to involve a complete care team to ensure the patient received the right information at the right time. Care coordination work group consists of physicians, nurses and administrators and include representatives from hospitals, practices, nursing homes and home health agencies. The inpatient team works to identify the high-risk patients that have been admitted, works to ensure they have a smooth discharge and hand-off to other members of the care community. Then we also have an ambulatory-care manager that works through the physician's office and is notified of the intending discharge and immediately follows up with the patient when they arrive home ensuring that the patients understand their discharge instructions, medications are reconciled and they have a follow-up appointment scheduled with their PCP. We will be engaging patients in their care—both through the contact from the care managers as well as by using patient portal technology, which makes the patient a critical part of our Beacon Care team. Next slide.
We are assuming there are basically three models or tools for health information exchange by community HIEs. The first model that was used by [unclear: 18:19] was the pull model where patient information is pushed to a local or regional data repository and made available to clinicians that are involved in the treatment of their patients. Some have called this the ‘Google approach' because clinicians often use portals to search for their patients and then pull up information from multiple healthcare providers. The second model used in some places is the push model, where a clinician can identify themselves as having a treatment relationship with specific patients. Then when one of these patients is seen by other providers, the counter information is pushed out to the subscribers much the same way news feeds and blog updates are delivered to subscribers today. And the third model has been around for some time. It was originally called clinical messaging, and it's another kind of push where a clinician must select where they want the information to be sent. Messaging capability has gained traction through the ONC's direct project, which is basically a secured email approach. Health information service providers, or HISP, allow clinicians to send secure emails to other clinicians using secure email addresses supplied by the HISP. And a network of these HISPs is being developed today that will allow messages to be sent across communities. While someone had suggested that the new direct model could replace the more robust but expensive pull model health information exchange, we believe that a combination of all of these [unclear: 19:58] is necessary for a robust HIE. We wouldn't think—we would think that it would be absurd for someone to suggest it. We really don't need Google because we already have access to email, so both of those tools are important. Next slide, please.
This is just the basic diagram of our HIE connections. At the center we have an enterprise Master Patient Index, or MPI, along with a virtual document repository where we make information available. You can see many stakeholder organizations can be connected to that health exchange for various business purposes. Some of those are critical to our program that includes providers on the left and bottom of the diagram all the way to the right side where the patient becomes an empowered stakeholder in the care system. And ultimately payers have a role in the system both as a data publisher and consumer. And, of course, we must include standard tools for exchanging information with other health exchanges, whether that be through HIT connections for pushing information or through the nationwide health information network connect infrastructure. Next slide.
There's a large gap in the care system today with long-term care and home health organizations often being left out of the discussion. These long-term and post-acute care, or LT PAC, organizations play a key role in the care process and must have an effective way to share information. We began our Beacon program. We invited LT PAC organizations to participate. We found that many of them did not have EHRs. We learned that the long-term care is done submitting information electronically using minimum data sets to CMS, and by creating transformation tools, we're able to take MDS or [unclear: 21:59] data from home health and convert it into nationally recognized standards called continuity of care documents, which can be readily shared with other care providers. Next slide, please.
And finally the patient portal allows us to engage our patients in their care. It's critical to provide them with tools to help them manage it. We'll give them the ability to access clinical information that's available to other members of the care team, provide them with access to personalized education materials, send secure messages directly to other members of their care team and provide the ability to scan and upload that three-ring binder that they've been carrying around for years. We'll also give them the ability to enter information about themselves, such as medication history and give them the ability to electronically manage their contents to ensure their information is appropriately shared with other members of their care team. Next slide.
So by using the Keystone health information exchange, we've been able to connect information between all the disparate members of our care community, aggregate the information and transform it, standardize it and deliver it to the point of care. Thank you.
Joseph Conn: Jim, thanks so much. Dave, now over to you.
David Muntz: Good morning. I have to admit that after listening to the two presenters, that I'm suffering from enterprise HIT envy. They're doing a great job, and we are just on the mist of our journey. Baylor Healthcare System is located in Dallas, Texas. We're a $4.8 billion revenue company. We have about 3,300 beds. We see patients at about 200 different locations. We have 19,000 employees here, and we own a physician practice that employs 550 physicians. And we operate 14 hospitals at least where we have some responsibility, and before I start, I do have to provide acknowledgement to Carl Couch, who is the leader of the Baylor Quality Alliance, which is our name for our ACO, and the work that he's done. And, what I'm going to share with you today is not the details of what we've accomplished so much in IT, but how it is that we're selling this to our board and our community to make sure that everybody gets onboard. Going through a change in magnitude that we're going to experience here requires getting everybody enthusiastic about making the change. Normally people don't mind change; it's transition that they don't care for so much, so anyway next slide, please.
The case is easy to make: The Institute of Medicine study published more than 10 years ago shows some pretty dramatic and unflattering results from healthcare and we still haven't made the progress that we'd like to make. If you look at the IOM—Institute of Medicine—Triple Aim here on the right-hand side, what I've done is put the text that we're using to talk about clinical integration with our enterprise, and you can see I've underlined the data for care, data for improvement is really important. What I am going to talk a little bit about more is some of the other foundation that was laid because as you all are very much aware, information technology is an enabler but it certainly is not able to do the most important work, and I think the patient-centered medical home is the thing that we're most proud of, at least progress with me there. Next slide, please.
Now, if I'd been able to find a picture of Dr. Welby, and I'm not sure everybody knows who that was, it would probably be a better picture here—that at least everybody knows the Snoopy cartoon and how much he cares about the individuals around him. Anyway, the whole point of a patient-centered medical home is you have a comprehensive relationship with a physician, and the way we can do that is by giving the physicians the tools that they need and providing the linkage that they need in order to do possible the best thing possible. And where you hear a lot of discussion about IT disrupting the patient-physician relationship, I think that in this situation it probably has a better way to strengthen it so we're very proud of what it is that we're trying to do to help IT. Next slide, please.
The patient-centered medical home is an essential foundation. We've drawn a graphic here. We can see here that coordinated care, the enhanced access, the ability to do all of this in a way that makes logical sense to folks is critically important. Some of the employers are now requiring patient-centered medical homes, and so it's not just important to be able to do the linkage with people in the community, but it's also going to be important to link up with employers. Next slide.
What we do is create joint principles of the patient-centered medical home. And you'll see that the first three bullets there have the deal where the patient-physician relationship and the idea that we need to be very holistic and take care of our patients' significant change from what we are doing now. Then you can see the remainder of the bullets all have to do with care coordination and the tools that are going to be necessary and the fact that we need evidence-based medicine in clinical decisions and support tools available to the individuals who are involved at the point of decisionmaking. And finally access to care, and then finally you can't forget the administrative requirements, and so payment is an appropriate thing to look at. One of the things that is not surprising is the way that physicians have been trained in medical schools in the past to not allow them—or did not encourage them to act in teams. Next slide, please.
And you can see here that the message from George Halverson from Healthcare Reform Now is pretty dramatic talking about the fact that we are not operating as a team, and one of the best things that I've seen that's really remarkable and encouraging is the desire now to become a really fine home team, and I think Baylor Healthcare System has made a great, great progress towards that, and it's because we started this journey so long ago. The patient-centered medical home helps enhance the need for that, and if you will look on the next slide, you will see reference to our Mavericks, and these guys do play like a team. And it's amazing what you can accomplish even when you may not have the best talent but you have the greatest desire and you operate more as a team than anybody else. Next slide, please.
The greatest barriers to ACO formation as reported in the healthcare survey listed below: With a lack of integrated IT systems, that still is a grave concern of ours and we're certainly working hard to do all of the things that were described by the previous two presenters. Next slide.
And the slide that we use when we are talking to our board and to anybody else in the community is shown here, and this is an actual diagram of the interface that we use at just one of the 14 hospitals for which we have responsibility. And people ask me if I'm alarmed about the complexity of this slide. And the answer is absolutely not. It's not what I know that concerns me. Next slide, please.
It's what exists in the stand-alone systems, if you can read that print on the monitor in front of you. Just the fact that we still have so many disconnected sources, and though we're successfully changing data in a laboratory and health information exchange through enterprise, it's still these systems that aren't computerized, the stand-alone devices that are existing that cause me greatest concern. And the next slide.
And you can see here the informational building blocks needed by an ACO, and the fact that health information technology departments are all working on all of these things at the same time. Probably the most important one there is the ability to do analytics and the reporting, but without the rest of these things you certainly cannot be successful. Next slide, please.
And what are we looking at on broader best-in-class IT tools as we're setting up our ACO? And you will see that all of the things here listed are things that we have under way. And we're excited about being able to do those things. And finally the last slide, please.
It shows that we are now in an opportunity-rich environment. The challenge, I think, for all of us is the speed, accuracy and flexibility, and I think one of the other things that I didn't put up here that probably concerns me more than any other single factor. And that is: the degree of change that all of us are going to have to undergo and the ability of the human individual and, the human systems to be able to absorb that change. Finally, decision support. We talk about it all the time in terms of clinical activity, but we're also going to have to make sure that we have administrative systems that will allow us to be effective in managing the activities associated with the support cooperations. And that's the end of my comments, and I'll turn it back over to the moderator.
Joseph Conn: Thanks very much, Dave. I got a chuckle out of opportunity-rich environment. I'm going to have to remember that next time I'm feeling overworked and overloaded and just recognize my blessings about having an opportunity-rich environment. I wanted to allow the panel members to have an opportunity for about the next five minutes or so to ask questions amongst themselves, and maybe our readers are—or listeners—will be edified by hearing that. And so I will get to that in just a moment, but I wanted to remind our listeners that they can submit questions, and you have about five minutes to think something up and get it submitted into us. So with that, I wanted to talk with Steve a little bit and ask him if he has anything that he found of interest of his colleagues here.
Steven Heilman: Yeah, thanks, Joe. I appreciate that. I meant to ask Jim a question. We're getting started in our HIE initiative and how to get connected, and I just want to see if there is any big lessons learned as he was heading up his network and getting out there and getting it open to everyone?
Jim Younkin: Yeah, that's a great question, and I'll tell you there aren't any easy answers. The answers are simple, but not easy. I would say that the biggest challenge is probably setting up your governance structure to ensure that all of the members of the community are coming to the table on equal footing, and it can be a challenge, especially if you have larger health systems that are used to having a lot of power. And ensuring that your governance is set up in such a way that even the little guy has a voice at the table and they can ensure that the information that they're sharing is being protected and not used for any kind of competitive advantage.
Joseph Conn: Thanks, guys.
David Muntz: This is David. I also have a question and that is how you dealt with the issue of privacy and also consent?
Joseph Conn: This is directed toward Jim?
David Muntz: Jim.
Jim Younkin: Yeah, sure. The question that a lot of HIEs are addressing differently. Our legal counsel at Geisinger required us to err on the side of caution and being conservative, so we are using what is known as an opt-in model where patients actually have to sign an authorization form allowing their health information to be shared. So without the patient opting in, clinicians can see that their patient has received care at a particular facility, which is kind of directory information, and if they don't have the authorization, they can at least call and say, ‘Hey, I saw there was a visit there, can you provide us with—you know, fax something over to us?' But if they did provide their authorization, of course then their medical information is opened up.
Joseph Conn: I'd like to follow it up, Jim. Have you done any sort of metricization of who's opting in vs. who was deciding not to?
Jim Younkin: In terms of like demographics, or?
Joseph Conn: No, just on the numbers. I was listening at the AHIMA conference last week in Salt Lake City to one of your colleagues who was making a presentation on an HIE, and they did opt-out, and so they were saying it was like less than one-tenth or one-seventh of 1% of the people that were their registry opted out, so I don't know if you have similar data?
Jim Younkin: Yeah, we do. It's not quite as good on the opt-in side because it requires additional work, and we're asking our registration people, who are overworked anyway, to collect one more piece of information. So it's really dependent on the location where the authorization is being obtained. What we found is if the registration people take the time to explain the purpose of the authorization, that we have close to 100% of the population that agrees to sign it and go forward. But having said that, we know that there's a lot of locations where that patient education is not being done. And in those cases, it's probably less than 50% are actually planning the authorization.
Joseph Conn: So it appears that opt-in, per say, is not the barrier. It is the ability of the organization to provide that educational component, in your experience, has been the difference.
Jim Younkin: Yeah. That's correct. Once patients understand what it's for, I think the majority really want their healthcare information to be available to all the members of their care team, and in fact many patients today assume that we're already doing this. You know, they see the computers in their doctor's offices, and they just, you know, figure that their information is available electronically. And they're many time surprised to find out that it's not being done.
Joseph Conn: OK, well Jim you've been on the receiving end on most of these questions, so you want to ask one of someone?
Jim Younkin: Well, sure. I'm, of course, interested in both of the other speakers' terms of their experiences with HIEs. Maybe, David, you mentioned that you're working within an HIE in your area. I just wondered if you could comment on how that project is going and where do you see some of the barriers there for your organization to participate?
David Muntz: Sure. Good question, and I will kind of put it into two pieces. We actually have a couple of different efforts under way. But the first one that is making great progress is the enterprise health information exchange, and our logo has a blue flame on it and we like to say that if a patient goes to any facility—and this is from more than 200 access points that had the blue flame on it—they're going to have an expectation that we're going to be able to exchange their data. And we grew differently. We didn't start as a single organization, and so we have separate ambulatory records, we have a separate inpatient records and we have some joint ventures, and so in order to allow the patients to—the physicians to—get information seamlessly, we do have a centralized data repository for both the inpatients and we do contribute information. We're starting to contribute from some of the ambulatory, but you still have to figure out how to work with your joint venture partners. And so in order to do that, we have set up an enterprise health information exchange that's working in the laboratory now that we're getting ready to roll out by the end of the year that will allow us to do that kind of sharing, because we believe it's critically important. We will not only allow the physicians who belong to our Health Texas Providers Network—about 150 physicians participate in that—any other community physicians who also would sign up. We also are actually engaged in the community level, but the truth is Dallas has had three different starts on trying to create a health information exchange in the community here. Our most recent one was partially funded by the ONC, so we're a lot more hopeful, and we are making more progress there. But in spite of what happens in the community, we still feel we have an obligation to do what's necessary for the enterprise. We hope that when the enterprise is up and running it will be a single connection to whatever happens in the community. But we are very supportive of what's going on in the community. The difficulties that I asked you about with managing consent and how to do privacy are more complicated as you get into the public environment. But I think your comments about governance are also a big point that we have addressed and gotten an agreement on, so that's why I think we're going to be successful. And hopefully in the near term, too,
Joseph Conn: We have a lot of questions that have come in from the audience, which is a good thing, and we have about 19 minutes to go in our program. So I'd like to get to them now. I think all of your questions were really interesting as well. Small housekeeping question for Steve. Your slide showed EDW, I think I know what the answer to that question is: What is an EDW, but—and you mentioned it in your presentation—but one of our listeners asked, so—.
Steven Heilman: It's enterprise data warehouse. That's right on the slide, so—yeah, it's just basically a repository where we can store all information from different systems into one place.
Joseph Conn: Very good. I want to follow up with a question from the audience for you, too, Steve, while I've got you going here. It says, ‘Does Norton subsidize IT for affiliated physician practices, and, if so, how much to date or how much per year?' And I presume you're trying to leverage if you're doing that—leverage the meaningful-use money. And how is that working out?
Steven Heilman: You're correct. We are currently rolling out, like I say, the new EMR for all of our enterprise, and so with that we are offering a subsidized solution to physicians, but we're still early in the phases, so we have not determined what that subsidy is going to be at this point. In our marketplace, it's a fairly competitive market. Most of the physicians are already employed or affiliated with organizations at this time, so we're having to put some long-term view in this in terms of how this is going to look over a period of time, and what happens when Stark relaxation kind of goes away? So what's appealing, how far we're trying to spread, so I don't have a straight answer for you, and I'm sure maybe some of the other panelists probably have a better idea. But at this point we're working on the model and trying to put the [unclear: 42:56].
Joseph Conn: OK, thanks. Jim, let me ask you this one: Is it an option for Geisinger physicians to participate in the Beacon model, or are they required to, as part of Geisinger, employment?
Jim Younkin: OK, so you're asking whether or not our employed physicians are required to participate in the Beacon model.
Joseph Conn: Mmm-hmm.
Jim Younkin: And, I guess, you know I didn't get into a whole lot of details about what's involved in the model. It's really a patient-centered medical home model that we have been using really since 2006 that has been funded primarily through our health plan. And those physicians have adopted it. I don't know how much of it is by choice, but we do know that in the beginning physicians tended to be a little bit more resistant to having care managers in their practices. But after they start to see the benefits of having the care coordination and the value of the care manager really picking up the ball and carrying it through so the physician can go on to other things, they end up becoming champions of the process. And so we've taken that model that we deployed at Geisinger, and now we're applying it to an entire community regardless of the payer, and we're seeing the same kind of pattern where the physician early on needs to be kind of convinced of the value, but we're starting to see some breakthroughs in those areas as well.
Joseph Conn: Thank you. Next question's for Dave, and this is from the audience. It says, ‘For Baylor Healthcare, do you have any EMR system that you're planning to use? You have that pull-out there with the disconnected systems that are out all on their own, and I looked at that. And how many of those are going to be worked in, and what would your strategy for doing that as well?' I think that's probably the least relevant, but do you have an EMR system that you're planning to use?
David Muntz: The answer is yes, but it's a little more complicated than just a single system. The fact is that we use a particular vendor's offering and our own practices, and that's been very successful, and I should say that, by the way, about 65% of our physicians are primary-care—the rest are specialists—and so it's a little tougher when you get into the specialist community to be able to modify the templates to make sure that we're collecting all the data. And what we talk about or the term that we like to use here is we like to hard-wire STEEEP, where STEEEP is ‘saves timely equitable, efficient, effective patients in their care.' So that's our goal. But what we know when we get to the community is that you cannot be successful if you only offer one package to all physicians, and so we're picking out what we think are the most popular packages in the communities, and then what we're offering is a templated version of—or Baylor templated—version of those to the physicians who are interested in participating. And the advantage to us is that we're going to be able to exchange data more easily, we'll be able to offer more assistance to the physicians as they are setting up their practices and have questions about what is necessary. And for people who are going to participate in an accountable care organization, you not only have the requirement to do quality reporting and to exchange some of the administrative data, but I think one of the things that's interesting about the way we do employ our patient-centered medical home is there are citizenship requirements that talk about what it is that the patient's physicians should do and how they should interact. And so we're looking at patient satisfaction very carefully along with the reminders that physicians need to offer their patients to make sure for example they have smoke detectors and carbon monoxide detectors and wear seatbelts, so we're pretty pleased about that. And we're trying to make sure that the options and the alternatives that we look at have the capabilities to support not only the data but the citizenship are required as well.
Joseph Conn: Thanks. Dr. Heilman, I'll let you take this one. How can one quantify the benefits of a collaborative care model?
Steven Heilman: I think you have to kind of take it apart in different pieces, but a lot of this is looking ahead and saying that ‘In a fee-for-service model, life as we know it will not continue to go on indefinitely.' We cannot continue to spend the amount of money that we're spending on healthcare in terms of Medicare and Medicaid costs and offset that to the private insurance companies forever. So, the challenge we're in right now, we feel are to keep our service model, but we're exploring new products to figure out how in an alternative care models can you look at this and still remain functional. Our mindset is going into it saying, ‘How can we work on this so that our overall costs—that goes back to what everyone's trying to do, provide that value—lower our costs significantly so if we can figure out how to do a certain procedure or manage a certain instance of care at the lowest possible cost but the highest possible quality, then as we move closer to what they envision to become a capitated model, we know how to do that well. And already learning early lessons on hip replacements among a few other projects we're working on with clinical effectiveness, we're already starting to work with some of the payers. We've got a bunch of payment models to see how we can get reimbursed, because we believe we can do this well now, and that's how it's kind of hard to say what's the value in it now because I could make more money if I just do more fee-for-service, but I think you just have to look to the future and figure out where you're going to be in the future if you don't start making those [unclear: 49:39] now.
Joseph Conn: Thanks, doc. Jim, I think this one is probably in your yard. Are payers reviewing patients' CCDs that have been exported from provider EHRs for clinical suggestions and re-importing the CCD?
Jim Younkin: Good question, because what we're really talking about is that there's a lot of value in that clinical information that if it can be harvested and analyzed and to try to identify gaps in care, so let me say on one side Geisinger Health System has been doing this for a number of years where we have a data warehouse that we push information to from both the clinical and payer side of our health system. We run analytics to look for those gaps in care. We provide those alerts out to the members of our care team through our electronic health record, so it's not specifically the payer that's doing that so much as it is the clinical side of our house and providing it in a way that can support the treatment of those patients. We're trying to do a similar thing at the community level, and, again, pulling the CCD is on our road map, and it's definitely part of our plan to compare that across multiple organizations as well as compare it with existing, known payer information to look for those gaps in care and push it out through our health exchange to any of the members of the care team, so it's not being done today and it's not planned to be done as part of a payer but it is certainly on our road map as part of a community initiative that could very well be a tool that's used in an ACO-type model.
Joseph Conn: This is a combination question here. One of them is for you, doc, and it regards the data and quality improvement, the case-mix index data and that sort of stuff that you presented. Was there anything special that was done to increase the CMI so dramatically through your hospitalists, and any additional training focuses on better documentation. And for Dave and Jim, your question is basically how do Baylor and Geisinger react to the Norton CMI improvements and use of hospitalists? So, doc, let me ask you that question first—your end of this. Was there anything special that was done to increase the CMI so dramatically? Do your hospitalists have training focused on the documentation?
Steven Heilman: Sure. Absolutely. So, we underwent some fundamental changes, one in terms of employment in the last two years we've been fairly aggressive in hiring specialists, so when you look at the doctors that we employ, we're about a 50-50 mix between specialists and primary-care physicians at this point. What we did though as we started to employ people like neurosurgeons, we started to have those cases admitted to hospitalists, which we also employ. So, needless to say, the hospitalists who were predominantly taking care of pneumonia patients and things like that, now are starting to manage those neurosurgical patients. So we start looking at CMI. It's going to go up as a result of that, plus, you know, they're managing all the orthopedic side, even general surgery cases, so the direct effect is more related to managing more specialty are that prior to hiring and employing all these people were managed directly by the specialists themselves. And that's where I think the care—One: Does the patient perceive they're getting better care because they're being seen by a hospitalist who is managing their diabetes problem, or more appropriately? And then their surgeons focus more on their post-operative care after they had a procedure done, so it's a win-win for everyone, essentially.
Joseph Conn: OK. The follow-up question is: How do Baylor and Geisinger react to the Norton improvement s, and, Dave?
David Muntz: Well, I'll go ahead and say that we're having the same experience, and I think it's exactly what Steve said as well as the fact that we have revisited all of the work flows as a precursor to going in and installing any of our systems. And one of the goals is to look at what the data outputs are, you know, it's pretty classic implementation activities to make sure that we're collecting all the pertinent data, again, not just for clinical but also for administrative purposes. And so our goal was to make sure that if we change those processes, that we're throwing off data as part of the natural collection of information and not just doing it because we have to, and so our ability to make reminders or collect data automatically has allowed us to have a favorable impact on those items that show just how much work we're actually doing.
Joseph Conn: Jim, your reaction to this improvements?
Jim Younkin: Sure, I mean, I think it sounds like it's excellent work that's going on in both of those organizations. Here at Geisinger, I'm not as close to that kind of work here, but I would say that one of the things that Geisinger has done is implemented a proven health program where we started with certain surgical procedures, and by creating a checklist directly into the electronic health record to ensure that every step of—I can't think of the term, but evidence-based medicine is implemented into the care of those patients to the point where we can guarantee the cost of those procedures so that the hospital shares part of the risk and we can ensure that the best care being delivered at the best cost and that the health plan and the health system can share in the risk under that model.
Joseph Conn: Thanks. We're about out of time. I have one question I've got. It's for all three of the presenters, and you've got maybe 30 seconds to answer each. But here's the question: How do you get physicians to participate? Is it voluntary? Is it a requirement of the employed physicians? And how are the independent private physicians encouraged to participate? What makes them want to participate? And some of them are the cost or paid for by the IDS systems? Those are the questions. Basically, how do you get the docs to play? So, doc, let me ask you first.
Steven Heilman: Well we in our model that we set up now it's basically part of the employment. The employed physicians are asked to participate essentially. I would say it's voluntary but essentially everybody's agreed to do so. And we haven't really reached out to the independents yet because we're trying to figure out how you get around some of the legal ramifications if there's shared savings and you're trying to make that work. How do you stay out of trouble legally in terms of Stark, things like that?
Joseph Conn: OK. Jim? OK, we lost Jim there for a second.
Jim Younkin: Oh, sorry, I was on mute. Within our health system, certainly the physicians participate in the use of health IT have done for many years, but when you talk about the community physicians, and particularly projects like ours where we're trying to connect all of the different sites to health exchange, you got to make the right thing to do, the easy thing to do, and demonstrate the value to them, so I think it has to be voluntary at that level. There's certainly incentives in place now with CMS, and we just have to get them onboard long enough to see what the value is, and we think it will continue to grow from there.
Joseph Conn: OK, Dave, real quick.
David Muntz: Sure. I think that one of the things that is happening is that you're going to see the community's standard of care increased, so that if you don't use the record, you just won't be meeting that community standard of care, and that's a huge pressure. But I like what you said about—what Jim said about—it's the right thing to do. I just think it's the smarter thing to do, but we do—or we are going to require that anybody who is going to participate in our quality alliance actually have one of these systems that they will exchange data, because we can't operate any other way. And so, it's not forcing people to do it; it's just saying that the better way to practice care requires that you have the technology that would support that.
Joseph Conn: Well, I'd like to thank all three of our guests for participating in this webinar, and that will conclude our program for the day. I'm going to turn the control of this over to our editor, and we'll go from there. Folks, thank you very much for listening.
David May: This concludes today's discussion on mastering how hospitals and health systems are making better connections through information technology. For those who want to view the webcast again, all attendees will receive a follow-up email with a link to the recording of the webcast available at modernhealthcare.com/webcast. All slides presented during this webcast are also available at that address. Thank you.