Rob Waters, Director Program Development with Healthcare IT Connect caught up with Todd Rothenhaus, Chief Medical Officer with athenahealth to discuss population health management and what it takes for providers to be successful in the ACO marketplace.
Todd has been with athenahealth since April 2011, and is a nationally recognized expert on the implementation of electronic health record systems and the use of information technology in support of effective and accountable care. Prior to joining athenahealth, Dr. Rothenhaus was CIO of Steward Health Care (formerly the Caritas Christi), the second largest health system in New England.
Rob Waters (RW): Todd, since ARRA’s HITECH Act was implemented in 2008 to help practices implement EMRs many new programs have rolled out by CMS to help providers deliver more accountable care, how have these programs impacted your customers needs overall and how has athenahealth responded to these needs?
Todd Rothenhaus (TR): I think the first part of the question is what programs? I think we saw an immediate change up from what we had for ‘meaningful use’ in a cash for clunkers deal where suddenly people spent millions and billions on IT systems to meet ‘meaningful use’ yet were completely unprepared for the needs of executing and succeeding under accountable care. So while the original idea was that we were going to put computers in front of everybody and they were going to magically change things, we found that EHRs in of themselves are completely inadequate for solving core issues around population health management. The stimulus program wasn’t long sighted enough to push this industry forward, and now there is a need for new capabilities.
RW: Clinical integration is one of the first steps for providers to participate in new care delivery models such as ACOs and PCMH. Does athenahealth support providers with this strategic planning component?
TR: Yes, absolutely and in fact going back to your earlier question, what we found at athenahealth is that the customer’s needs have just not been met by the current crop of EHRs. Practices need a strong foundation in traditional revenue cycle. They need to be able to gain some margins so that they can start to begin to pay for all the initiatives that they need to launch under PCMH, or an accountable care umbrella. There is no better time now to clean up fee for service, and it’s the first step. The second step is looking at your office and asking yourself are you even ready to take on anything new? The example that I like to give is you go to the dentist and he or she has five hygienists, 25 chairs, and there is a factory working that’s able to very quickly see people. Then you walk to a physician’s office and there is one guy, one MA and three rooms, and the place is jammed up and they have no way of getting people in and out. There is some substrate of clinical performance getting people in and out, contacting them and working them between visits, that needless to say is what we call healthcare. We have gone from a 1:10 ratio of doctors compared to everybody else in the health system now to 1:15. We’ve got negative productivity in healthcare and we need to fix that and we need to fix that at a micro level.
It’s got nothing to do with EHRs in that you have glorified word processors that people were selling as the first generation of EHRs. There is workflow support that needs to happen. If you take that one step further and things are financially stable, and you are performing because you can get people in and out efficiently and you can contact them and work with the between visits. Now you can concentrate on clinical effectiveness and I don’t think that the industry has responded well here. We have got a lacklustre performance in meaningful use. Meaningful use is identical to any other pay performance program. They are all numerators, denominators exclusions, and if you can’t get meaningful use what hope can you have in managing quality as part of an ACO.
RW: Performance data transparency is often viewed as a critical component of improving both clinical and financial performance amongst ACO participants. Is this an area you are tackling?
TR: Absolutely. The first step toward data transparency is that every primary care doctor in America has patients who access caregivers in other spots and they don’t know about it all. Every health system in America has patients who seek care elsewhere, here in Massachusetts we have got a provider organization at which 65% or 70% of the dollar cost of care of their patients is delivered by a competitor, and so those organizations need to basically capture market share. They have always had to, and they still need to do it. These organizations would probably rather pay themselves as opposed to paying a competitor for services that they can deliver under a risk-based contract and so that level of transparency is only obtained when you got a complete picture of what has been paid for the patient. This type of administrative claims data represents a foundational layer of data access for executing on a contract. The other piece of data transparency is once you have decided that you want to reduce utilization. We are not seeing a hospital system too anxious to reduce utilization, but we are seeing our independent medical groups in a perfect position to reduce utilization. Once you are ready to do that providers need to be able to shop and what I mean by that is they should make the referral from labs, radiology department, and other physicians. They ought to be able to see how much that person charges and what those costs are and how the quality is and again getting that data and having that delivered to the point of care is what we are doing here at athenahealth.
RW: Many providers are also looking at the opportunity to integrate claims and clinical data into the analytics tool set. At what stage should they be doing that and should every ACO be looking to achieve that in a relatively short amount of time?
TR: I deeply believe that if an organization is actively managing patients in a risk-based contract that the next dollar they spend should not be on anything but understanding the total cost and the total picture of the population health through the claims based analysis. If they don’t have that, they can’t succeed. No amount of other technology will help them succeed. I believe that the addition of clinical data to the claims data assets is an essential next step, but I think that sucking data out of antiquated EHR systems that are under the desk of a doctor’s office or in a data center is a really nasty business. I am hopeful that there will be some standards based integration solutions that will help them do this without breaking the bank. We at athenahealth of course support standards based interfaces for free, but asking us to suck data out of the backend of another EHR, it isn’t necessarily a best use of everybody’s money. So, the first dollar must go to claims, the second dollar to clinical data.
RW: Cloud computing platforms are often referenced by leading health IT vendors is away to help providers deal with the myriad of healthcare data required for improved clinical and business decision making. What makes athenahealth’s offering different and how does this impact your customers ability to succeed in the new transformed healthcare?
TR: Well, that’s a great question=. We are in the cloud and we consider that now an unfair advantage as we compete against other vendors with a traditional software model. First and foremost the costs of IT are the next enormous bond burden that non-profit hospitals are carrying. They are spending extraordinary amounts on information technology without any link to outcomes.The cloud offers a truly more economical solution to any healthcare IT project. Most of the start ups you see in healthcare today are cloud-based to some degree because nobody is building technology in a traditional software model. Yet,legacy EHRs that are out there and are in use have never been ported and probably won’t be ported to the cloud.
Our ability to help our clients succeed is really based on the fact that they are all on the exact same instance of our cloud-based solution, and that we are able to provide them insights as to how they are performing down to the minutia. For example, we know exactly how long every doctor on athenaNet, our cloud-based network, takes to complete a chart. We know exactly how many days an average doctor has in his inbox of labs and radiology studies that he or she needs to review after they’ve ordered them during a patient visit. So that transparency that we are able to create and the fact that we can join them in the work of taking work out of the practice is what we consider comparative advantage in the 21st century. Doctors, nurses, and other care providers shuffling work off to lower cost people who should be performing that work, like Medical Assistants. So there is this way of basically insulating the clinician who is really the only billable unit in a medical group and who has studied for 8 to 10 years from having to do what’s commonly referred to as scut work and that makes it a better way. It’s life changing for physicians to not have to fill out all those administrative forms that they used to have to fill out.
RW: As the healthcare industry moves away from fee for service and payers and providers collaborate around shared saving and other risks based models (ACOs and PCMH), What do you see are the biggest challenges over the next five years for providers to attain those savings you know, required for these models to be successful and to become predominant?
TR: That’s a great question, we are already seeing some of the pioneer ACOs start to complain that it was too hard and are thinking about leaving that program so this is a very timely question. I really think there are two things that will separate. I do think attention to tools is a critical component. I think that if people think that EHRs plus HIEs are going to solve the nation’s healthcare problems and help them succeed under risk that they are wrong. We now have a new industry of population health management tools that everybody needs to use, too and, unfortunately, I think there are those who are stuck thinking that their $100 million or $500 million investment in a hospital EHR is the solution. They are in fact wrong. The second component is really the timing, understanding the way the money works and timing the intervention. Timing the tactical execution in the contract. I see organizations all over the country that are instituting care management as the first step towards accountable care and what they are really doing is adding cost. Unless they are in a risk-based contract it is very hard to capitalize on the reduction in utilization to come. So there is a proper order of doing this and I think that very few people understand it. CFOs need to start grabbing the reins a bit back and saying, we’ve got to look at this contract and understand how to tactically execute it and in what order should we be doing things. This way CFOs can spend money reducing the utilization early on alone but still manage quality and coordinate care effectively as an initial step.
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