CASE STUDY TULANE UNIVERSITY MEDICAL GROUP OVER 400 PHYSICIAN MEMBERS WITH A DIVERSE RANGE OF EXPERTISE, ACADEMIC PURSUITS AND CLINICAL INTERESTS 866-888-6929 www.eclinicalworks.com sales@eclinicalworks.com 1
CASE STUDY Tulane University Medical Group Dedicated to Quality Medicine as Part of an Academic Health Center The Challenge Although an early adopter of electronic medical records, Tulane University Medical Group has faced an ongoing need for more effective data aggregation techniques and analytics to help its physicians provide quality care to an urban population with high rates of preventable chronic diseases. The Solution Combining population health and data analysis tools from eclinicalworks, Tulane s physicians and data analysts have successful harnessed data from multiple providers and across multiple platforms, producing medically useful information for greater effectiveness at the point of care. The Results Tulane has forged a true partnership with its healthcare IT provider, developing customizable tools with the speed and flexibility needed to provide quality care to a diverse urban population, while also positioning Tulane as a national leader in identifying and solving long-term and newly emerging challenges in population health. New Orleans on the Medical Frontier Since its founding in 1718 until the present day, New Orleans, Louisiana has enjoyed as complex and colorful a history as any city in the U.S. And since the founding in 1834 of the Medical College of Louisiana the forerunner to today s Tulane University School of Medicine the city has had an important presence in American medicine. Today, Tulane University Medical Center (TUMC), jointly owned by Hospital Corporation of America (HCA) and Tulane University, is the primary teaching hospital for the Tulane University School of Medicine. TUMC and its affiliated physicians, Tulane University Medical Group, stand on the forefront of Population Health studies, including the integration of healthcare IT technology to broaden medical understanding of how to deliver effective healthcare to populations in need. The last two-and-a-half years have been a real turning point, not just here at Tulane, but for medicine in general, with the advent of tools to manage Population Health, said Dr. Timothy S. Harlan, who is Medical Director at TUMG, a noted author, and Associate Chief of General Internal Medicine and Geriatrics for Outpatient Programs at the Tulane University School of Medicine. Our success in the last two years has been predominantly in building out our infrastructure, and using the CCMR tool that eclinicalworks offers us has been the key to that success, he said, referring to the Care Coordination Medical Record (CCMR), which was eclinicalworks pioneering web-based platform for Population Health management. We ve been able to create a team and do data aggregation using that tool in a way that was not possible for even medium-sized practices before now. Certainly not small practices! And I think 2
TUMC and its affiliated physicians, Tulane University Medical Group, stand on the forefront of Population Health studies, including the integration of healthcare IT technology to broaden medical understanding of how to deliver effective healthcare to populations in need. that s the beauty of the ecw tool, Dr. Harlan said. It s not just the Electronic Medical Record, but that kind of endto-end solution, where you start with eclinicalworks as your EMR, and are then able to aggregate that data from a myriad of sources. Dr. Harlan said. That functionality pulling data from multiple sources is fundamental to the effective practice of medicine today, particularly in New Orleans. The Reality Behind the Numbers One of the challenges that I think most are facing in healthcare is aggregating the data in a usable way and making sure it is accurate, says Nicholas Bernard, Director of Clinical Wave Analytics at Tulane. And that is one of the challenges that we have here at Tulane. We have a really unique patient mix. So, when patients come to receive care at Tulane, they also are referred to as outflow. So they can go to another healthcare provider all around the city. It s important that we are able to pull data points and information from a number of different providers and different areas. And CCMR and ecw really allow us to do that. The diversity of Tulane s patient population, and the fact that they seek help from many different providers, are not unique to New Orleans, but taken in combination with the health needs of the region, they present providers and their IT partners with an opportunity to do ground-breaking work in Population Health. You can pull that data from claims data, from collection data, from other EMRs, Dr. Harlan continued. Having that data, that platformagnostic data aggregation tool, has been a tremendous leap forward for us in our ability to analyze exactly what our patients are doing, what their care opportunities are, but also where we can help our physicians at a high level. There is no doubt that New Orleans physicians can use technology and data to make a real difference for their populations. The U.S. Census Bureau s 2010 American Community Survey 1 illustrates the range of the socioeconomic and health challenges 1 https://www.census.gov/programs-surveys/acs/ 3
facing New Orleans. The survey revealed that there are significantly higher rates of poverty and chronic illnesses in Orleans Parish and Louisiana as a whole when compared to national averages. The poverty rate for all families in Orleans Parish, for example, stood at 22.6%, twice the national average of 11.3%, while Louisiana had an overall rate of 14.3%. The U.S. Census Bureau s 2010 American Community Survey illustrates the range of the socioeconomic and health challenges facing New Orleans. The survey revealed that there are significantly higher rates of poverty and chronic illnesses in Orleans Parish and Louisiana as a whole when compared to national averages. Similarly, the survey showed that rates of heart disease, strokes and diabetes were all higher in Louisiana than in the U.S. as a whole. And survey data also show a strong correlation between those trends and rates of education and employment, which lag behind national averages. The January 2013 New Orleans Community Health Improvement Report 2 summarized those challenges: The effects of poverty on the health of our citizens can be seen through lack of access to affordable housing, food, healthcare services, as well as higher rates of unemployment, infant mortality and morbidity, and obesity than the national average, its executive summary stated. In addition, there is a 25-year gap in life expectancy between residents of one of the city s most economically depressed neighborhoods compared to those in the most affluent neighborhoods. But the report also offered hope: The New Orleans Community Health Improvement process represents a paradigm shift in how communities work to improve local health outcomes. This shift is marked by notions of health moving from a medical, individual healthcare, needs assessment model, to a framework that incorporates a broader idea of health focusing on populations, assets and identifying resources. 2 http://www.naccho.org/uploads/downloadable-resources/updated-nola- Community-Health-Improvement-Final-Report.pdf 4
6 States with the Most Cardiovascular Deaths in US* OKLAHOMA #2 Heart Disease Deaths per 100,000: 464.8 Stroke Deaths per 100,000: 99.5 ARKANSAS #6 Heart Disease Deaths per 100,000: 440.4 Stroke Deaths per 100,000: 104.1 2 6 MISSISSIPPI #1 Heart Disease Deaths per 100,000: 500.8 Stroke Deaths per 100,000: 99.8 1 5 WASHINGTON DC #5 Heart Disease Deaths per 100,000: 447.1 Stroke Deaths per 100,000: 68.4 LOUISIANA #4 Heart Disease Deaths per 100,000: 449 Stroke Deaths per 100,000: 91.1 4 3 ALABAMA #3 Heart Disease Deaths per 100,000: 461.4 Stroke Deaths per 100,000: 105.5 Heart Disease and Stroke Risk actors in Louisiana Compared to the US** Louisiana US Adults Who Are Current Smokers...24.8%...19.6% Adults Who Have Participated in Physical Activity in the Past Month...70.1%...77.1% Adults Who Are Overweight or Obese ++...69.5%...64.4% Adults Who Have Been Told They Have Had a Heart Attack...4.8%...4.5% Adults Who Have Been Told They Have Had a Stroke...4%...2.9% Adults Who Have Been Told They Have Angina or Coronary Heart Disease...4.9%...4.3% High School Students Who Are Obese...13.5%...13.7% *SOURCE: American Heart Association studies for 2015. **SOURCE: American Heart Association studies for 2014. ++Overweight is defined as having a body mass index (BMI) of 25.0 29.9. Obese is defined as having a BMI of 30.0 or more. 5
How has public healthcare improved in post-katrina New Orleans? Health in New Orleans today is about the prevention of disease and promotion of health and wellness. A broad spectrum of partners from across the community are working together to improve Population Health by making healthy choices easier, creating environments that promote health, and addressing factors that impact health outcomes. As a result, the New Orleans ranking in the County Health Rankings a report released by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute has improved for three consecutive years. KEY RECOVERY DATA 70+ Neighborhood health clinics in the region offer primary care, mental health and other services. 59,000 Working-class individuals in Greater New Orleans receive healthcare services through the Greater New Orleans Community Health Connection. 95+miles Bikeways and trails in New Orleans now compared to 10.7 miles in 2004. Tulane s Enduring Commitment Tulane has long focused on public health, with service and outreach to the Greater New Orleans community. Indeed, that has long been one of the chief reasons that the university and its associated medical community has been able to attract some of the nation s finest medical students, and retain them once they begin their professional careers. A lot of the area, both here and in downtown New Orleans and the greater New Orleans area tends to be underserved, says Zachary Stauber, a Tulane graduate with a master s degree in public health. They have limited access to healthcare and resources, and tend to be in many cases of lower socioeconomic status. That usually follows in turn with a bevy of chronic preventable diseases, and so it does require a unique approach to Population Health. Stauber said Tulane s commitment to outreach and community service, at both the undergraduate and graduate levels, was among the chief reasons he chose to stay in New Orleans. That commitment, he said, has existed since the university was founded, but has grown stronger and deeper in the wake of Hurricane Katrina, which struck in August 2005, flooding 80% of the city and killing more than 1,400 residents. In the decade since, New Orleans has undertaken a massive recovery effort, including rebuilding both infrastructure and social and community life. The role of public health has never been more important to the city, and Tulane helped lead the way with the creation of The Partnership for the Transformation of Urban Communities. 3 Right Partner, Right Team As director of the Medical Scribe Program at Tulane Medical Center, Stauber has seen firsthand the difference that the right healthcare IT partner can make. 3 http://renewal.tulane.edu/background.shtml 6
Some of the tools that eclinicalworks uses, and the ones that we ve begun to use, such as CCMR, really allow providers to make sure that they are providing as comprehensive a quality of care as they can at the point of care. As someone with a public health background, who s interested in medicine, it s something I m really excited about. I think it really increases the accountability of each physician, and I think overall it s going to help improve quality numbers across the board. At Tulane, for example, students in their first and second years of medical school have the chance to work in student-run clinics, something normally offered only to students in their third year and beyond. And the differences are reflected as well in the health system s choice of a healthcare IT vendor, eclinicalworks. Zachary Stauber Director, Medical Scribe Program Some of the tools that ecw uses, and the ones that we ve begun to use, such as CCMR, really allow providers to make sure that they are providing as comprehensive a quality of care as they can at the point of care, he said. As someone with a public health background, who s interested in medicine, it s something I m really excited about. I think it really increases the accountability of each physician, and I think overall it s going to help improve quality numbers across the board. Bernard and Dr. Harlan concur, and offer several examples of the progress they have experienced. I work in network operations with others across the region, Bernard said, and when you look at the other tools, they all want to do the same thing. We want to aggregate specific claims and specific EMR data so we can identify a particular population we want to intervene with. However, it s surprising. They say they can do these things, but then when you actually start to work with the companies, and you start to see what s really behind the doors, you see they haven t done a whole lot, because it s incredibly challenging. Bernard did find a few companies, however, that could really deliver on their promises. What we want to do is, when a patient goes into a physician s office, they pull up a specific scorecard on a patient to say Have they had their A1c? What was their blood pressure? Are they on 7
Within just eight weeks of deploying eclinicalworks, TUMG was able to capture about 85% of the data it needed for its Group Practice Reporting Option (GPRO) under the Physician Quality Reporting System. aspirin? Are they on statins? Bernard explains. When you go into ecw currently, it s one of those things that s a little slow. You press the little button within ecw, it s called Patient Hub, and when you press it and it pulls up all the care opportunities for that patient. The bad thing is, it takes around 10 to 15 seconds to load, and that s really just a little too slow for our physicians to use right now. With the onset of 10e and that type of environment, we feel that maybe if it s faster, that s a game-changer. Because if you look at the other EMRs that they have out there, it doesn t exist. We signed on in the very early days, Dr. Harlan adds. And those early days had their challenges. But the fact of the matter is we were able to get data really quickly. It saved us a lot of money. In fact, within just eight weeks of deploying eclinicalworks, TUMG was able to capture about 85% of the data it needed for its Group Practice Reporting Option (GPRO) under the Physician Quality Reporting System. And in the second year of using the tool, they achieved a 94% data acquisition rate. The folks at eclinicalworks have been huge for us in their level of cooperation, in their level of ability to customize this product in a way that makes sense, Dr. Harlan said. I d like to think they ve learned a little bit from us along this process, and I think that s what s made it such a fantastic partnership. So, how does that partnership play out in the real world? Results: Controlling Hypertension From a strictly medical point of view, it enables practitioners to achieve measureable progress in a variety of specific initiatives. For example, TUMG has been participating in the American Medical Group Association s Measure Up, Pressure Down campaign. Launched in November 2012, the campaign, which includes more than 140 medical groups, national partners, and sponsors, aims to have 80 percent of blood pressure patients be in control of their medical condition by 2016. 4 4 http://www.measureuppressuredown.com/pr/index_pr.asp. 8
Measure Up Pressure Down Created by the American Medical Group Association s Foundation (AMGF), Measure Up/Pressure Down is a threeyear national campaign to reduce the burden of high blood pressure. Measure Up/Pressure Down engages clinicians, patients, employers, and other key stakeholders to raise awareness and achieve lasting improvements in blood pressure control that lead the way to greater health for all Americans. 1 in 3 Nationally, only half of all patients have their condition in control. THE ISSUES 156, 000, 000, 000 50% Costs to the nation due to high blood pressure are estimated at $156 billion. U.S. adults (68 million) have high blood pressure, meaning that millions of Americans are at increased risk for heart disease and stroke. When you look at trying to extract those data for that campaign, we were completely unable to participate in that before about a year ago, Dr. Harlan said. Eighty percent of your patient population that s a pretty lofty target. And none of the sites within AMGA has reached that level. But most have gotten into the 72% to 75% range, but that takes a lot of work at the global level, where you can have clinical data analysts looking at the data, identifying opportunities for individual physicians and their individual patients. With the help of eclinicalworks, TUMG has made significant progress among a very challenging population. Tulane began at 59 percent control already better than the national average, and drove that figure to 67% within eight months of beginning the campaign. $$$ So we ve been able to move the needle pretty hard and fast, Dr. Harlan said. Our goal is, by the end of this calendar year, that we are above that 70% mark, and hopefully by the end of this academic year, hopefully approaching that 80% mark. When you stop and look at what that means to payers, but also to our patients, it s a lot of money. You know, 1% improvement in a patient population our size, results in about a $40,000 reduction in overall healthcare spending, so these can be dramatic movements of not just the health of our patients, but also in the total healthcare spend. 9
Results: Better Technical Architecture On the technical side, it means a more responsive and innovative approach to managing data. Finally, effective partnerships between medical organizations and their IT vendors are empowering providers and patients alike to put Population Health into a leading role in the future of healthcare They give you the attention and the resources in order to build out the specific things that are needed, Bernard said. We at Tulane have helped drive toward what needs to be designed on the back end for them and specific dashboards, and populating certain fields, and what you need to see from a claims perspective from the payer. I think that s where ecw really is gaining the advantage. It s in innovation and being unique in the fact that we know the direction we need to go, but we also know we re not there yet. It s a difference, Bernard said, that goes beyond mere technical competence, to include detailed know-how, and the ability to adapt the software to the needs of a given practice or medical system. It s unlike other technology companies, he said. They all know how to write code. They know how to query information. But it s all about where do I go for that information? How do I build the architecture on the back end? The fantastic thing about ecw is, it s incredibly customizable. We can develop different kinds of spreadsheets and data feeds to populate those tools. It s data that s then transformed into information, then transformed into knowledge, and then into wisdom. Results: A Healthier New Orleans Finally, effective partnerships between medical organizations and their IT vendors are empowering providers and patients alike to put population health into a leading role in the future of healthcare a welcome and necessary step toward a healthier society, and one that may be most effective in places where health needs are so great and gaps in care have traditionally been so acutely felt. The public should have access to some of this information, because that s how our health system, from a national perspective, is really going to improve, Stauber said. The fact that it s available 10
HITECH Act (Health Information Technology for Economic and Clinical Health Act) The Health Information Technology for Economic and Clinical Health Act (HITECH Act) legislation was created in 2009 to stimulate the adoption of Electronic Health Records (EHR) and supporting technology in the United States. President Obama signed HITECH into law on Feb. 17, 2009, as part of the American Recovery and Reinvestment Act of 2009 (ARRA) economic stimulus bill. As it was originally enacted, HITECH stipulated that, beginning in 2011, healthcare providers would be offered financial incentives for demonstrating meaningful use of EHRs until 2015, after which time penalties may be levied for failing to demonstrate such use. Providers could start using EHRs as late as 2014 and avoid penalties, but the amount of incentives they were eligible to receive would be less than earlier adopters. The rollout of meaningful use is happening in three stages; providers must demonstrate two years in a stage before moving on to the next one. Because adoption for stage 2 has been slow, the Centers for Medicare and Medicaid Services (CMS) announced in mid-2014 that it will put stage 3 off until 2017. through the internet, especially now you can access everything through the internet, so why shouldn t you be able to access some of this information in that same place? Here in New Orleans specifically, not all patients have access to the internet, but that number is going to continue to grow. And the technology will grow along with it. When you stop and think about how far we re come in 20 years from 1994, all of this interoperability, being able to communicate with your patients, being able to do really high-level data analytics, it s going to change the way we practice medicine in the next 20 years, Dr. Harlan said. It s a pretty exciting step forward. We selected ecw as our partner eight years ago, before there was a HITECH Act, before that whole concept existed. There s no question in my mind that it was the right choice. And yet, the most critical difference is not to be found with either the internet or technological improvements, however advanced. It is to be found with people. I feel privileged and honored to participate in providing care, Stauber said. It s something I take pride in, especially here in New Orleans, it really does require a unique approach to health because of the patient population. It s diverse, a bit of a mixing pot of people from all over the country. Practicing medicine here in New Orleans is really an exciting place to be right now. n 11
12 Tulane Medical Center 1415 Tulane Ave New Orleans, LA 70112 Phone: (504) 988-5263 http://www2.tulane.edu/som/fpp/