September 21, 2013 Managing Population Health in Northeast Georgia: One Medical Group's Experience By Mark Hagland Northeast Georgia Physicians Group (NGPG), based in Gainesville, Georgia, a suburb of Atlanta, encompasses 200 providers, of whom 140 are physicians and 60 are mid-level practitioners, and serves patients in 45 locations in 13 counties in mostly-rural northeastern Georgia. Most of the NGPG primary care physicians practice in very small groups or in solo practices, while the NGPG specialists practice in groups of 10-15 doctors. Early in 2012, the CEO of Northeast Georgia Health System, the parent company of NGPG, informed NGPG leaders that they needed to get all their primary care sites recognized as patientcentered medical homes by the end of the year. As a result, the medical group needed to be able to scale its care management process quickly to meet the PCMG requirements of the national Committee on Quality Assurance (NCQA). NGPG chose the x-based Phytel as a technology platform that could facilitate population health management activity, and could also integrate with the organization s electronic health record (EHR). Among the tools implemented by the group is a module that combines an electronic patient registry with automated messaging to patients who have preventive and chronic care gaps. Triggered by nationally recognized clinical protocols, the messages urge patients to make appointments with their providers. Recently, Antonio Rios, M.D., NGPG s chief physician executive, and Marlene McIntyre, NGPG s director of quality and patient safety, spoke with HCI Editor-in-Chief Mark Hagland regarding the progress that they and their colleagues have made in moving forward on population health management activities. Below are excerpts from that interview. Your physicians practice in smaller-group settings for the most part, correct? Antonio Rios, M.D.: In the case of the primary care practices, some are practicing in solo practices. Our biggest primary care practice has five providers. As for the specialty practices, sometimes 10-15 physicians are practicing in the same building. Marlene McIntyre, R.N.: We re spread across 13 counties, mostly rural, in northeast Georgia. So while a five-physician practice might sound small in a place like Atlanta, a five-physician practice is actually pretty big in a place like Dawsonville. Tell me about your journey around population health. Are you also involved in some version of accountable care development?
Rios: We re not necessarily presuming the accountable care journey. We realized a few years ago that we needed to redesign how we deliver care, and the medical home started to become a more prominent issue, and we definitely saw that as a goal for our group to pursue aggressively. And Marlene led three of our practices through NCQA certification through the patient-centered medical home. And because of that, we heard about a Centers for Medicare & Medicaid Improvement grant, through TransforMed. TransforMed is a division of the American Academy of Family Physicians. McIntyre: They ve become experts in care management. We re not looking to establish an MSSP [Medicare Shared Savings Program] ACO, but we ve definitely started going down the path of transforming care, to deliver better care for patients and to align ourselves well to better succeed in this era of healthcare reform and accountable care. We re a part of the Patient-Centered Medical Neighborhood grant; it is in effect for over three years for just over $21 million, and we re one of 15 community centers participating in this process. It equates to a little over $2 million for us. We kicked off in January. We re one of the 15 communities encompassing 90 practices, and eight community practices, of which seven belong to us, are participating, in our region. So what are you doing, in the context of that program? Marlene: We re developing these practices into highly effective PCMHs. That means changing how we deliver care, as well as automating a lot of processes through technology. That requires us to identify care gaps for patients when they come into the office, as well as, a pilot around our diabetics we re using the Phytel population health technology, and we re able to use some of their risk stratification tools to identify our most poorly controlled diabetics and work with them. Those initiatives both began in January? Rios: The three practices involved in the pilots already had the criteria for a media home, so we ve been working with those for close to two years, and that involves the diabetic initiative, as well as open access, sharing of information, revisit planning, etc. You re speaking of three of the seven practices that belong to you among the eight community practices involved in the Patient-Centered Medical Neighborhood grant, correct? Rios: Yes, three of seven. We started the process earlier with those three practices. Are all seven participating practices now NCQA-certified? McIntyre: No, and those three were certified under the 2008 standards, and NCQA rewrote those standards in 2011. Our three practices were certified in 2011 under the old standards. So we ve currently submitted our applications for all of the 22 practices in our primary care network certified under NCQA. And seven of our practices are in the CMMI grant.
In terms of the cultural aspect of this, has it been a struggle with the physicians in the group, or are they on board? Rios: There are several pieces to that answer. Traditionally, we ve been involved in a singlepatient-visit model of care. So culturally, it has not come easily or naturally for doctors to start shifting to thinking about being responsible for a whole panel of patients. So there has been some struggle with that, and I think we ve needed some help from other organizations to come talk to us. And it has helped for us to realize that as a physician, you do need to be responsible for a whole panel of patients, and that everything is interrelated. That has been one of the challenges. As you know, we physicians are not naturally one of the most predisposed groups to change. What s more, one of the challenges involved is that many of our providers are now working many extra hours outside the patient encounter to complete their documentation for coding, billing, etc. [in an EHR-based environment]. So unless you change things, the coming shortages are going to be exacerbated. So if we can sell our doctors on the idea that this will not only help our patients, which is the main reason we re doing this, but also that it will help them be more effective and improve their work lives. Downstrreaming of tasks from the physicians to mid-level practitioners and to non-clinical office staff, as appropriate, is necessary in order to make this work, correct? Rios: Yes. We have to look more at that. McIntyre: We re trying to really bring everybody to the top of their skill set and competency so that a lot of tasks can be done by front-office staff or mid-level staff, and then you can better utilize physicians. So it s downstreaming also from the mid-levels to non-clinical staff, too? Both: Absolutely! What kind of IT do you have? Rios: We started with our own EHR, optimizing end-user use of it, and then figuring out how to extract data. But Phytel gave us the ability to streamline analytics and to start looking at our population in a completely different way. When did you begin to implement and use the analytics capabilities? McIntyre: We started our implementation journey last summer and went live in November, but by January, we were robustly live. Rios: We started deploying not only within the seven CMMI grant practices in our group, but then within all 22 primary care practices. And we ve only begun to scratch the surface with what s possible. First, I can see what my patients need to do preventively, whether through mammograms, immunizations, etc. Secondly, among our diabetic patients, we ve been able to
select those uncontrolled diabetics, and have been moving them towards a more controlled state. And we wouldn t have been able to do that without the Phytel tool. What percentage of your diabetics are uncontrolled? Rios: It changes a great deal between practices, with a particular differential between the urban and rural practices. McIntyre: Some practices have more rural populations, and therefore lower health literacy and even general literacy rates. After the work we ve done in the last two years, among our poorly controlled diabetics, fewer than 8 percent of our patients have a hemoglobin a1c levels above 9; that s fewer than half of those who had previously had such levels. So now that we have the Phytel technology spread throughout the network, and that we have care managers across the organization, we started ask which patients we should be looking at more carefully. What we did was that we risk-stratified all of our diabetics and used care managers at all of our sites. And some places had only a few patients with poorly controlled diabetes, and others had far more. So we focused on those with the lowest level of control. But overall, 48 percent of the patients we took this hands-on, focused approach with, had an improvement. That was a sample size of about 860 patients at 10 locations, so it was 48 percent of 860 patients. And if you look at the individual clinic-level improvement, it ranged from a low of 32.7 percent improvement to 63.4 percent improvement. What constituted improvement? McIntyre: Those focused patients percentage who had a decrease in their hemoglobin a1c after six months, based on clinical lab results. Also, overall, the average decrease across those locations, was 1.8. And then if you were to look at the lows and the highs, the clinic with the highest decrease was 3.2 points; the clinic with the smallest was 0.71. But that clinic, going in, was the pretty well-controlled. A lot of the improvement comes from process change, right? Rios: Yes, a lot of education was involved, explaining what medications they should be taking and shouldn t be taking, and giving authority to the RNs to modify treatment, and they did, and it worked. Were there any big IT challenges? McIntyre: We could not have done this work without the population health technology in place. With my role in quality, I m all about data and digging into data. And this gave me easy access to the data we had. And in three clicks of my mouse, I could access this data, versus, historically, it would take months to get the data out of report-writing technologies, and it would be too late. And Dr. Rios can see real-time data for his patients in a couple of clicks, versus a quarterly report. So having that point of care, being able to pull that report today, has really been huge to us, because tried to do it within our EHR without this technology, and it just didn t happen.
Rios: Our providers need and want the technology now. And relying on historical claims-based data just doesn t work. Marlene: What physicians will say is that they remember their poorly controlled diabetics from recent visits, but not from among those who haven t been in for a while. Often, it requires identifying additional resources, connecting the dots, and helping those patients with their diabetic control over time. What should other medical group executives know about this? What advice might you give your peers nationwide? Rios: I think it s important, number one, for the leadership, to be on board with this concept. And number two, they need to be users, in trenches, leading by example. Do you have any specific advice about IT? Rios: Within the IT piece, there have to be clinicians on the same time as the non-clinicians, because they re the ones who will have to understand workflow and how it will affect practice. But answering the why question, why are we doing this, goes a long way towards getting other providers on board. McIntyre: And even though you might not be able to accomplish your ultimate goal, you need to start. And it s really important to identify what the data values and points are that are most important to the physicians, and work from there. If you aren t pulling data that s important to the physicians, all you re doing is pulling reports. Is there anything you d like to add? Rios: We ve been very lucky to find a partner that has been very supportive, but not pushy. But we ve been lucky to find a very good chemistry with our vendor. We re realizing that things are changing and change is inevitable, and we d better make the best of it. McIntyre: It s definitely a journey. http://www.healthcare-informatics.com/article/managing-population-health-northeast-georgiaone-medical-group-s-experience