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Learn how NextGen Healthcare solutions can help you to prepare for the changing rules of reimbursement and care delivery.
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Payment Rules are Changing. Are You?
It is a widely recognized fact that the current fee-for-service healthcare
reimbursement model is unsustainable. International reports indicate
that the U.S. spends a far higher percentage of its gross domestic
product (GDP) on healthcare than other industrialized nations, but
is losing ground in terms of average life expectancy and other clinical
markers.1 Clearly, the quality of care in the U.S. is not keeping pace
with spending. Several key factors provide ample evidence that current
costs are too high to maintain in light of their failure to correlate with
superior care. Most important, perhaps, is the fact that healthcare
spending has been growing faster than the economy for many years.2
Additional considerations include: the looming specter of Medicare
insolvency; the increasing Medicaid burden on states already struggling
fiscally; the growing number of employers unable to afford substantial
employee insurance coverage; and the resulting increase in patients left
either without health insurance coverage or with enormous deductibles.
Compounding these issues is the fact that the number of practicing
physicians is predicted to shrink in the coming years.
All of these elements are pushing healthcare toward new payment
models aimed at controlling costs by promoting better and less
expensive preventive care. This paradigm shift collectively is referred
to as “value-based purchasing,” and is ushering in a new era for
reimbursement and care delivery. What it will require is a dramatic
change in both processes and perspectives.
FEE-FOR-QUALITY: Preparing for the changing rules of reimbursement and care delivery
Copyright © 2013. NextGen Healthcare Information Systems, LLC. Patent pending.
This time the change is for real. Quality reporting initiatives are rapidly evolving into true pay-for-performance programs.
FEE-FOR-QUALITY:
Solutions for: Ambulatory | Inpatient | Community Connectivity | Performance Management | Consulting Services nextgen.com
For some, the term “value-based purchasing” brings to mind unsuccessful attempts
at managed care in the 1980s and 1990s. However, there are critical differences
between value-based purchasing models and past managed or capitated plans.
Chief among them is the link connecting care quality with reimbursement.
Under past managed care plans, participating providers received fixed payments per plan
member each month, regardless of care volume or quality. Providers therefore received no
financial benefit from lowered general healthcare costs. They had little financial incentive
to provide the “extra” preventive services likely to increase overall patient care quality.
Seeking to learn from past mistakes, government and commercial payers began unveiling
programs a few years ago offering incentives to providers in exchange for reporting data
on certain key clinical measures. Medicare’s initial Physician Voluntary Reporting Program
(PVRP) pilot in 2006, for instance, quickly evolved into the Physician Quality Reporting
Initiative (PQRI)—now called the Physician Quality Reporting System (PQRS). While
Physician Quality Reporting remains voluntary at the moment, physicians will begin to
suffer negative adjustments to reimbursement if they do not participate by the year 2015.
In other words: This time the change is for real. Quality reporting initiatives are rapidly
evolving into true pay-for-performance programs. The new organizing principle of
healthcare, according to author Michael E. Porter, is about achieving the highest value per
dollar spent. In addition to lowering costs, attention is directed at gaining health value for
patients. Rather than fee-for-service, both care delivery and reimbursement policies are
beginning to emphasize fee-for-quality.
Making “value” the watchword
Medicaid offers one example of payer programs moving away
from fee-for-service toward capitation and shared savings
pools based on population health management. The attitude
is best summed up in a quote from Neva Kaye of the National
Academy for State Health Policy: “I wouldn’t say that fee for service is a
thing of the past, but it doesn’t produce the outcomes that states very much
want.”1Having offered various forms of managed care for years, Medicaid
plans increasingly are mandating care coordination for patient populations.
At the federal level, physicians are not the only ones with reimbursement
tied to fee-for-quality endeavors. Hospitals have received bonuses to report
on quality measures since 2004; now, Medicare is taking the next step
toward genuine pay-for-performance. The agency is adding new financial
incentives to spur more coordinated, holistic patient care by tracking
spending per beneficiary. Hospitals will be held responsible for the cost
of caring for patients in the 90 days after discharge. Those that keep costs
lower per capita will be paid more, while those with “less efficient” care
will receive less.2
This concept of shared savings/shared risk may be somewhat new to
Medicare, but it has been gaining steady ground within commercial
insurance contracts. Some form of pay-for-performance now is built into
most major payer contracts, often revolving around quality outcomes
requirements and preventive care coordination objectives. Instead of
fearing them, healthcare organizations must seize the opportunities
these programs offer.
Demonstrations reveal that non-participants in pay-for-performance
contracts risk leaving reimbursement—and patient outcomes—on the table.
One case in point is the Marshfield Clinic, an 800-physician multispecialty
practice with affiliated hospitals located in Marshfield, WI. As a participant in
Medicare’s Physician Group Practice (PGP) Demonstration Project, it earned
bonuses in each of its first three performance years.
Perhaps surpassing the importance of incentive dollars, however, were
improvements to patient care that drove down overall costs. As a result
of program participation, Marshfield Clinic redesigned care management
services to reduce hospital admissions and readmissions for select patient
populations. By improving the outcomes for patients needing anti-
coagulation therapy and diabetes care, for instance, the clinic gained more
than $30 million in Medicare savings over three years.3
By lowering costs and enhancing the patient care experience, pay-for-
performance contracts are advancing the transition from costly acute,
episodic care to more proactive, population-based care management. At
the heart of a successful transition, however, is data.
Having offered various forms of managed care for years, Medicaid plans increasingly are mandating care coordination for patient populations.
Required: System-wide redesign
Prominent emphasis on proactive patient management represents a departure from traditional operating models
for most healthcare organizations. Thus, it typically will require comprehensive evaluation and redesign of key
processes and systems. Organizations that successfully master the transition to the value-based purchasing era
will do so through a four-step evolutionary process:
Tapping the benefits of data and technology If there is so much to be gained from population health management, why hasn’t it been done already? There is
a simple answer to that logical, often-asked question: Before now, technology did not exist that could support the
extensive real-time data management necessary.
In reality, it is advances in technology that finally are enabling the care coordination and health management essential
to value-based purchasing initiatives. True quality care demands visible patient data among all stakeholders—facilities,
providers, and patients themselves. In the past, paper-based processes severely limited that visibility in several ways:
• Providers only gained patient information through access to the physical paper chart;
• Providers only had information about patients who presented to their unique place of service;
• Providers only had access to data about past and current health needs—not proactive needs
based on “best practices” clinical protocols.
By contrast, automation now breaks these barriers and lets providers care for ALL patients—not just those who present
to the office—efficiently and cost-effectively. Through technology, for example, providers can send personal preventive
care reminders to each and every one of their hundreds of active patients as needed—a far better, more efficient
mechanism than offering verbal reminders to the handful of patients who happen to visit. Further examples can be
found in two current models of care delivery: the patient centered medical home (PCMH) and the accountable care
organization (ACO).
Obtain the ability to
gather and report on
cost and quality data. It is
impossible to consistently
improve anything without
data against which to
benchmark progress.
The implementation
of electronic practice
management systems,
electronic health records
(EHRs), and network
interconnectivity are
crucial platforms supplying
the data on which new
healthcare models are
being built.
Develop performance
management processes.
With data acquisition
comes the capability to
redesign workflows. Data
analysis must be used to
support process changes
that enhance patient
outcomes, operational
efficiency, and cost savings.
This is the step during
which organizations begin
to actively manage
clinical knowledge.
Manage the chronic and
preventive care of large
patient populations. The
cornerstone of value-
based purchasing is the
concept that keeping
patients healthy should
work two ways: reduce the
cost of care and enhance
outcomes. But keeping
patients healthy requires
the ability to track and
act upon wide-scale
data reflective of care
recommendations, care
provision, and outcomes.
Generate patient outreach
and involvement that
support “patient centered”
care processes. The final
step in the value-based
equation is empowering
patients with the
information necessary to
take responsibility for their
own care. Ultimately, it
is the encouragement of
proactive, healthy patient
behavior that will have the
most impact on national
costs and outcomes.
STEP 1: STEP 2: STEP 3: STEP 4:
True quality care demands visible patient data among all stakeholders—facilities, providers, and patients...
PUTTING PATIENTS ON THE TEAM:
The PCMH approach
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The PCMH concept is a team-based approach to care, relying on a
virtual network of doctors, nurses, and other providers who share
information to better coordinate care. It is often described as a hub-
and-spoke model because it places patients and their primary care
physicians together at the center of all care decisions. From that “hub,” care
is coordinated with ancillary “spokes” as necessary—specialists, pharmacists,
hospitals, home health, etc.1
PCMH requires the integration of patient data across the spectrum of care—
including the patient as well. As espoused by the National Committee for
Quality Assurance (NCQA), care within a PCMH “…is facilitated by registries,
information technology, health information exchange and other means to
assure that patients get the indicated care when and where they need and
want it in a culturally and linguistically appropriate manner.”2
For organizations that have successfully integrated PCMH standards into
their operational and clinical framework, key benefits typically include: better
chronic disease management; an increase in preventive care for patients;
and subsequent reduction in “preventable” chronic disease admissions and
emergency department visits. Crystal Run® Healthcare, for example, is a multi-
specialty PCMH practice in New York that that has achieved well above average
rates for patient compliance with screening mammography. It has done so
by combining systematic, patient-centered, coordinated care management
processes with evidence-based guidelines and age-appropriate preventive
reminders embedded in its EHR.3
The next step: “accountable” care models
Accountable care organizations are closely aligned with the PCMH ideal, encouraging care coordination
among providers across all healthcare settings. However, they go a step further to integrate the
reimbursement concept of shared risk/shared savings among many healthcare entities. Providers are joined
with other members of the healthcare system and are held accountable for both the cost and quality of care
delivered to an entire defined patient population. It is important to note, though, that they are very different in concept
and implication from the managed care plans of the past.
Patients in accountable care organizations are not limited to seeing only certain providers; they are free to choose and/
or change providers at will. In addition, accountable care groups are not capitated plans. Rather, providers receive fee-
for-service payments plus additional bonuses. Providers actually share with the payer the financial value gained from
population management.
As might be imagined, these organizations are data-intensive. They require systems capable of performing such
functions as: setting benchmarks; measuring performance; administering payments; and distributing shared savings.
In return, participants can expect benefits including: stronger margins from improved productivity; increased network
referral capture; and reduced hospital readmissions.
One example can be seen in two CIGNA accountable care pilot initiatives that have been developed based on strong
patient-centered care coordination. Preliminary results from both initiatives have shown positive results. One is closing
gaps in care 10 percent better than the market, while the other has lowered average annual costs per patient by $336.1
Care coordination, automation: Essential elements for high-quality, cost-effective careAs fee-for-service reimbursement models vanish from the healthcare landscape, fee-for-quality models quickly are taking
their place. Value-based purchasing increasingly is offering a premium for those able to foster proactive, population-
based care management.
Yet healthcare organizations must understand that the intensive patient care coordination processes required by
ACOs, PCMHs, and other value-based models are only possible through automation. Manual processes are simply too
inefficient and costly to provide the real-time data that the future of medicine will demand.
According to one study, it would take an average 22 hours per day per doctor to manually track and coordinate patient
care.2 That would mean hiring two FTEs per doctor, at a national average annual salary for a nurse practitioner or
physician assistant of about $89,000. That equals an increase of $189,000 per doctor—just to try to manually coordinate
patient care.
The cost equation aside, automation also allows providers to focus their energy where it belongs—on patient care.
By easing the data gathering, analysis and paperwork burdens that are fast becoming the expectation in healthcare,
automation frees providers to spend more time offering better patient care. In the end, that is the true value gained by
value-based purchasing.
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Providers actually share with the payer the financial value gained from population management.
Discrete data capture and analytics are the keys to achieving success
in the value-based purchasing market. Perhaps the greatest problem
confronting healthcare organizations today is the fact that data analysis
requirements gradually are becoming more and more granular. It simply
isn’t feasible any more to depend on basic, text-based chart notes.
Your IT systems must give you the ability to capture, parse, and report on everything
from recommended care protocols to care provided, as well as outcomes statistics,
patient satisfaction ratings, and scores of other data elements. In addition, they
must bring patients fully into your information flow and decision-making processes.
Many may try relying solely on an electronic health record (EHR) to perform all
of these data-intensive tasks. Yet the truth is this: An EHR alone will get you only
partway toward the patient-centered, accountable care of the future.
Healthcare is quickly moving in a direction that requires data and tools that put
patients at the center of their own care management. In practical terms, that means
provider-facing EHRs will need to connect with a number of other, patient-facing
applications.
NextGen Healthcare recognizes the growing need for tools that let information
flow seamlessly across the continuum of patient care. That’s why, in addition to
the discrete data capture enabled by our 2011-2012 CCHIT Certified® NextGen®
Ambulatory EHR,* we offer other advanced, flexible solutions to help you transition
into the uncharted new era of patient-centered care.
NEXTGEN HEALTHCARE SOLUTIONS: Answering the demands of fee-for-quality
*NextGen Healthcare’s NextGen Ambulatory EHR version 5.6 SP1 is 2011/2012 compliant and was certified as a Complete EHR on September 30, 2010, by the Certification Commission for Health Information Technology (CCHIT®), an ONC-ATCB, in accordance with the applicable eligible provider certification criteria adopted by the Secretary of Health and Human Services.
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Take, for instance, our unique automated patient outreach: NextGen Population Health
Integrated within NextGen Ambulatory EHR and configurable at the system level, NextGen®
Population Health provides an automated approach to truly patient-centered proactive patient
engagement. By comparing patient information against your protocols and automatically
contacting patients who need services, it brings a new level of efficiency to care coordination
and maintenance.
Let’s take the example of an organization that wants to increase its screening mammography
compliance rates. A care coordinator traditionally might run monthly
reports to pinpoint those patients due for mammography, then
manually reach out to each with a phone call. While somewhat
effective, it is a costly and labor-intensive solution.
Achieve faster outreach more efficiently and effectively. Here’s
how: You set parameters for identifying eligible patients in the system,
then task it to perform the desired outreach—perhaps an email first,
and if no patient response, then an automated phone call, followed by
the creation of a task requiring a call by the care coordinator. General
text messages and secure portal communication could also
be incorporated.
As an integrated feature of NextGen Ambulatory EHR, NextGen PH
also automatically documents the reason for patient outreach. As
value-based purchasing gains traction, this kind of documentation will
be critical when trying to prove your attempts to engage patients to
payers, employers, and others.
NextGen PH maximizes automated information flow while preventing
patients from “falling through the cracks,” allowing you to efficiently
and cost-effectively track and evaluate ALL of your patients—not just
those with the highest risk factors. Additional benefits:
• Integrates fully with NextGen® Practice Management
(including scheduling and Autoflow), NextGen Ambulatory EHR,
and NextGen® Patient Portal technologies for maximum
effect and efficiency
• Supports fee-for-quality initiatives
• Opens the lines of communication beyond
the current encounter
• Increases the number and quality of patient
touch points
NextGen Health Quality Measures (HQM)In conjunction with NextGen Population Health, the NextGen® Health Quality Measures reporting module helps
you prospectively and retrospectively identify patients eligible for treatment opportunities. It can feed into NextGen
Population Health to automate proactive patient outreach. Plus, as a clinical data repository, it enables automatic
registry reporting of outcomes and quality data. (In fact, we are the fifth largest registry—and the only EHR vendor in
the top five.)
All providers need to do is document encounters within NextGen Ambulatory EHR and NextGen Practice
Management as they normally would. NextGen HQM automates the cumbersome data collection, analysis,
and reporting processes.
NextGen Health Information ExchangeNextGen® Health Information Exchange is an interoperability package that lets the NextGen Ambulatory EHR swap
standards-based data with any health information exchange (HIE) in real time, within normal provider workflow. It’s a
highly secure central data repository, where incoming information from various sources is parsed and stored.
Developed on a Microsoft® .NET platform— with
Microsoft Web Services interfaces to external
systems and to NextGen Healthcare systems—
NextGen Health Information Exchange can be
used to support four distinct integration profiles:
1) NextGen Healthcare users
2) third-party EHR systems
3) hospital systems
4) providers with no EHR solution
(via a Web-based provider portal)
In addition to connecting with a wide variety of HIE backbones, NextGen Health Information Exchange collects and
transports discrete data—enabling you to enhance content-driven clinical workflow. It not only transports data, it
permits NextGen Ambulatory EHR software to read and understand it. What that means: You can use the inherent
meaning of your data to improve patient care.
Rather than just reporting the medications prescribed by multiple providers, for instance, NextGen Health
Information Exchange will identify that a generic drug prescribed by one provider is the same as the
brand-name drug another provider is considering — and generate the kind of critical alert that advances
patient safety and care.
NextGen HQM collects encounter data in real time,
allowing organizations to easily analyze it in four
distinct ways relevant to fee-for-quality reporting: BY1. Denominator
2. Numerator
3. Exclusion parameters
4. Treatment opportunity
NextGen Patient PortalWhile patient portal technology isn’t required to meet current Meaningful Use or quality reporting
standards, it’s important to continually keep your eyes on the future.
Consider, for instance, the fact that Meaningful Use is likely to soon mandate that patients have self-
management care plans. That will pose a novel challenge for healthcare organizations: How are you going
to make it easy for patients to report their progress toward those self-management plans?
The NextGen® Patient Portal:
• Eases patient reporting on self-management of their conditions
• Offers secure, HIPAA-compliant patient communication
• Engages patients with minimal practice resource consumption
• Takes a critical step toward true patient-centered care by encouraging patient
responsibility for their own healthcare
In addition to easing provider-patient communication, our portal solution offers added workflow
efficiencies. Appointment requests, prescription renewals, and document transmission are only the
beginning. Portal information can be imported directly into NextGen Ambulatory EHR and linked with
customized disease and health management plans. By integrating the portal with tools such as NextGen
Population Health, you can bring value-based care full circle, ensuring seamless information flow through
all aspects of patient care.
NextGen Healthcare understands that technology is not the solution to enhancing care quality and
reducing costs. Technology is merely the vehicle; information is the solution. NextGen® technologies
present you with a vehicle truly capable of delivering that vital information, giving you the cost and
quality data necessary for success in the fee-for-quality age.
SOLUTIONS IN ACTIONFive NextGen Healthcare Clients on the Forefront of Patient-Centered, Accountable Care
Achieving truly patient-centered, accountable care is an evolutionary process. It
requires continually redesigning procedures and systems to perpetually drive the
quality of care forward.
We know. NextGen Healthcare has been helping clients successfully assess and
redesign their processes and systems for years. With each new client, we share and
build on the practical experiences of those who have come before.
Perhaps that’s why we have so many clients far ahead of the curve, practicing
“patient-centered” and “accountable” care long before the terms were coined.
Here are the stories of just a few…
Four-physician family practice - Gilbert, Ariz.
Gilbert Center for Family Medicine (GCFM) has prided itself on providing
“evidence-based” and “patient-centered” care ever since the doors
first opened 25 years ago. For many years, GCFM physicians tried to use
evidence-based guidelines to drive care decisions. Yet there was no way
they could truly track and trend the care they gave to each patient—at
least, not in real time. The resources it took to manually track data weeks,
months, or years later made it hardly worth the effort.
In 2003, with patient volumes soaring, GCFM began looking for ways
to eliminate paper processes in order to decrease clinical liability and
increase workflow efficiency. The group decided to implement the
NextGen Practice Management system followed by the integrated
NextGen Ambulatory EHR.
Plus, GCFM became the first practice in Arizona—and one of the first
nationwide—to earn advanced recognition as a National Committee
for Quality Assurance (NCQA) Level 3 Patient Centered Medical Home
(PCMH). The goals of PCMH reflect GCFM’s long-standing commitment
to employ the best possible information technology (IT) tools and
processes to build patient relationships and enhance the total healthcare
experience.
GCFM uses about 60 evidence-based reporting tools to help improve
care management. In addition to tracking chronic problems such as
diabetes, hypertension, and hyperlipidemia, the group measures
compliance with evidence-based guidelines for patient wellness services.
Practice-wide reports determine patient wellness needs and generate
automated reminder calls to encourage patient compliance. If necessary,
these are followed by personal calls from medical administrators (MA)
and/or physicians.
Because of the structured data fields captured in the NextGen
Ambulatory EHR and NextGen Practice Management systems, GCFM is
evaluating and analyzing seemingly every clinical goal or administrative
function it performs. It further supports robust information flow across
the continuum of care through use of the NextGen Patient Portal,
NextGen® e-Prescribing functionality, and NextGen HIE with two area
hospital groups, and numerous interfaces with labs, a radiology facility,
pharmacies and more.
The chief benefit of PCMH, according to Practice Manager Jim Stape,
is awareness. Each physician now possesses the information needed
to better recognize every opportunity to improve care quality—day by
day, patient by patient. In fact, one of the lessons GCFM offers other
practices is this: Don’t purchase an EHR and other IT because they mirror
the way you do business with paper charts. Be prepared to do business
a new, better, and more efficient way.
Results At A Glance:
“It’s all about the reporting. Without discrete data, you simply cannot compile accurate reports.” -- GCFM Practice Manager Jim Stape
80% of GCFM performance reviews
are statistically generated from
analysis of the NextGen Ambulatory
EHR/practice management database.
All tasks performed in the office are
counted using reporting techniques.
Clinically, GCFMs patient-centered
approach has resulted* in…
• Compliance for wellness initiatives:
in the 90th percentile
• Compliance with diabetes HbA1c
control: in the 99th percentile
• Compliance with diabetes
nephropathy monitoring: in the
90th percentile
• Compliance with mammography
screenings: over the 90th percentile
• Compliance with LDL cholesterol
control: over the 90th percentile
* all results compared against Mountain HMO/POS HEDIS
Gilbert Center for Family Medicine
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200+ multispecialty providers Hudson Valley, New York
Crystal Run has long emphasized a patient-engaged and data-driven
model of healthcare delivery. As far back as 1999, the group determined
it needed to implement an EHR in order to support aggressive growth
plans—as well as simplify the logistics involved in accessing clinical
information. It wanted to make healthcare more accessible to patients,
and improve quality of care.
However, the group quickly recognized that it needed an EHR that
would allow it to mine clinical data to enhance disease management
and preventive care programs; improve patient compliance with care
plans; communicate better with patients regarding urgent issues
(such as drug recalls); and develop specialized programs to address
the needs of defined patient populations.
Today, all 200+ providers at Crystal Run’s 11 locations are linked together
by the group’s common NextGen Ambulatory EHR and its NextGen
Practice Management system. In addition, it’s preparing to link with other
regional practices via a regional health information exchange. It was the
first private practice in New York to attain accreditation from the Joint
Commission, and was one of the first practices in the country to earn the
coveted National Committee for Quality Assurance (NCQA) certification
as an advanced, Level 3 Patient Centered Medical Home (PCMH).
All patient data is input to the system—including chart notes, referrals
and consultation reports, prescriptions, and orders. Full use is also made
of radiology, prescription, and lab interfaces. Patient data is accessible to
providers from virtually anywhere, with Internet connectivity via a secure
virtual private network (VPN). The practice has adopted the BlackBerry®
platform to mesh its clinical systems with communication services.
Using NextGen Ambulatory EHR tools to manage patient data and drive
decision-making factored heavily into Crystal Run’s PCMH certification.
The group showed, for instance, how it has helped improve compliance
with chronic disease case plans by handing patients a history of their
own vital signs to demonstrate progress—or lack of progress—toward
personalized care goals. In addition, patients identified as high-risk for
certain conditions are enrolled in appropriate disease management
programs and assigned a care coordination nurse.
However, neither the Joint Commission nor the PCMH certification
would have been possible, says Chief Medical Officer Gregory Spencer,
MD, FACP, without a practice-wide process in place to determine how
data is collected, analyzed, and acted upon. Choosing which quality
Results At A Glance:
Data at Crystal Run is used to
identify high-risk patients for certain
conditions, and enroll them in
appropriate disease management
programs where they are assigned
a nurse who regularly reviews the
medical record to assess risk factors
and coordinate appropriate care. All
data is collected and organized in an
automated fashion, and presented
in a summary template. With this
approach, Crystal Run achieves:
• nearly 90% compliance for
mammography screening for breast
cancer
• similar results in colorectal, cervical,
and prostate cancer screenings, and
bone density screenings
Internet and wireless connectivity
results in faster clinical results, such as:
• 98% of INRs (anticoagulation)
reported within one hour of being
obtained
Crystal Run Healthcare
measures to track is the job of clinical division leaders and physician-led committees such as the Quality Committee or
the Patient Safety Committee. They pinpoint the exact data needed to report on those measures, then work with the
IT and business intelligence (BI) departments to ascertain whether the desired measures are feasible from a technical
standpoint.
While some practices might focus on reporting only those measures at which they excel, Crystal Run takes a more
proactive approach, using published measures to drive internal quality improvement. It encourages individual
physicians, departments, and the practice as a whole to measure against external benchmark data. This is how it has
achieved Joint Commission and PCMH certification, and how it plans to continue prospering in the coming era of
value-based purchasing.
30+ multispecialty providers Beaumont, Texas
The two forward-thinking physicians who founded Southeast Texas
Medical Associates (SETMA) in 1995 believed in the power of continuum-
wide healthcare integration. Just three years after opening its doors, it
implemented NextGen Ambulatory EHR. The goal: to preserve the health
and quality of life for all patients—efficiently and cost-effectively.
SETMA now uses NextGen Ambulatory EHR to securely connect three
clinics, two hospitals, emergency departments, 22 nursing homes,
provider residences, and six non-clinical locations (e.g., business office,
home health, hospice, physical therapy). The group also maintains a
reference laboratory and mobile x-ray services.
It wasn’t until 2009, however, that SETMA set out to demonstrate its
pledge to quality improvement—to both patients and payers alike—by
pursuing National Committee for Quality Assurance (NCQA) recognition
as a Patient Centered Medical Home (PCMH). Its achievement of
advanced Level 3 recognition testifies to its understanding of the vital
need for data analysis to: change provider and patient behavior; change
practice procedures and processes; and improve patient health through a
focus on preventive care.
SETMA focused on disease management during its initial implementation
of NextGen Ambulatory EHR. But by 2009 it realized that the future of
patient-centered care required the ability to audit provider performance
and patient information in real time against national quality-of-care
standards. As an organization, SETMA wanted to progress from meeting
those care standards on a patient-by-patient basis to measuring
treatment across broad patient populations.
Results At A Glance:
The reporting functions at SETMA
all are designed to overcome both
provider and patient “treatment
inertia.” They’re working:
• Treatment compliance is at 98%
for SETMA providers in regards to
guidelines for preventive services
and chronic conditions such as
diabetes, CHF, and hypertension
• Diabetes recognition and affiliation
from the NCQA Diabetes
Recognition Program and the Joslin
Diabetes Center (affiliated with
Harvard Medical School)
• NCQA recognition as a Level 3
Patient Centered Medical Home
• AAAHC accreditation in ambulatory
care and medical home surveys
Southeast Texas Medical Associates
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So SETMA created a unique Model of Care that emphasizes five key elements: data tracking, auditing, analyzing,
reporting, and improvement:
• Tracking—providers track performance of preventive, screening, and quality standards for acute and chronic
conditions while in the exam room with each patient.
• Auditing—audits over a given patient population evaluate care patterns by provider, practice, and the entire
clinic. Each audit seeks to pinpoint opportunities for care improvement, and is done using IBM® Cognos® business
intelligence (BI) functionalities.
• Analyzing—performance audits are analyzed statistically to measure improvement by practice, clinic, and provider.
Care discriminators—ethnicity, age, gender, payer, treatment frequency disparities, etc.—are reviewed for care
improvement potential.
• Reporting—On its website, SETMA publishes hundreds of quality reports for each provider with two goals in mind:
1) To motivate and inspire other providers to improve performance, and 2) To be transparent with patients to build
greater confidence in their doctors. Patients also receive personal “plan of care” reports to encourage them to be
active participants in their own care.
• Improving—analysis tools identify appropriate quality improvement initiatives to pursue.
The discrete data capture capabilities of NextGen Ambulatory EHR now are used by SETMA’s providers daily to measure
their performance of “best practice” standards against all applicable quality measures. Before a patient is seen, for
example, his or her chart is searched to determine if all HEDIS, NQF, PQRS, PCPI, AQA and NCQA standards have been
met. Nurses independently initiate the completion of preventive and screening services according to age requirements.
At a more global level, dashboards identify population-wide trends so that changes can be made to practice policies to
improve care.
The practice also built into NextGen Ambulatory EHR the ability to generate individualized reports for patients that
itemize which services—according to quality measures—should be performed. These tools allow patients to initiate
needed services, increasing satisfaction by giving them more control over their care.
By tracking provider performance against benchmarks in real time—and simultaneously offering patients the information
they need to improve their own care—SETMA is continuously raising the bar on patient-centered care.
Desert Ridge Family PhysiciansSix-physician family practice - Phoenix, Ariz.
Desert Ridge Family Physicians opened its doors in 2004 already dedicated to a progressive model of care that
included open access scheduling, a commitment to evidence-based medicine, and a patient-centered philosophy.
The group was fortunate enough to undergo implementation of NextGen Ambulatory EHR prior to opening,
giving providers the opportunity to develop EHR-based workflows from the very beginning. The practice now
takes advantage of the data analysis and patient outreach benefits of NextGen Ambulatory EHR, NextGen Practice
Management, and NextGen Patient Portal.
Multispecialty - Southern California
HealthCare Partners is a physician-owned, coordinated care system
based in Torrance, Calif., that was formed in 1992. Since then, it has
grown to become one of the largest medical groups in California.
Along the way, it has developed an extraordinary vision: to be a role
model for integrated and coordinated care, leading the transformation
of the national healthcare delivery system to assure quality, access, and
affordable care for all. Perhaps not surprisingly, it is also a NextGen
Healthcare client.
As one of only five organizations selected for a national pilot to test
the efficacy of the Accountable Care Organization (ACO) concept,
HealthCare Partners has uniquely decided to integrate three distinct
electronic health record (EHR) systems within its various provider
communities. One of them is NextGen Ambulatory EHR.
As a result of this ambitious plan, HealthCare Partners is tackling the
challenges inherent in building an internal health information exchange
(HIE) among disparate technologies. Simultaneously, it is working to
develop external HIE connections with other healthcare organizations,
and use the results of real-time data exchange to improve care processes.
In fact, HealthCare Partners has begun to meld health information
technology (HIT) to front-line point-of-service patient care, as well as
overall patient outcomes. The group’s stated IT goal is to make the
appropriate data available to the appropriate provider at the point,
time, and manner that best facilitates patient care. Real-time quality data
sharing, mining, and reporting are being combined to create a richer
environment for integrated care.
Although a small practice, Desert Ridge is actively pursuing the achievement of Meaningful Use from its technology;
it attested for Meaningful Use Stage 1 in 2011. In a recent hearing on Capitol Hill on early Meaningful Use adoption,
practice administrator Dan Nelson testified, “We have seen firsthand the benefits that EHRs can provide, and we credit
our EHR as the backbone of many of the quality improvements and initiatives that we have implemented.”
“We are particularly excited about MU Stages 2 and 3 because of the improvements in quality of care that we expect
to see,” Nelson also told Congressional leaders. “[We] carry immense pride in the quality of patient care that our EHR
system allows us to provide.”
Results At A Glance:
The vision of HealthCare Partners
is to lead the transformation of
healthcare toward more patient-
centered, accountable care. Its vision
is becoming reality:
• 90% of patients consistently
award top satisfaction scores
to its providers
• Integrated Healthcare Association
(IHA) has recognized it as a top-
performing California medical
group for the past seven years
based on clinical quality measures,
patient experience measures, use
of information technology-enabled
systems, and coordinated
diabetes care
• It was named a finalist in the
Adaptive Business Leader (ABL)
organization’s 2010 Innovations in
HealthcareSM 12th Annual ABBY
Awards—honoring companies that
have proven ways to lower the cost
of providing quality healthcare
HealthCare Partners
nextgen.com
1 OECD Health Data 2010. How Does the United States Compare. Web. http://www.oecd.org/dataoecd/46/2/38980580.pdf
2 Centers for Medicare & Medicaid Services. National Health Expenditure Data. NHE Summary Including Share of GDP, CY 1960-2009. Web. http://www.cms.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage https://www.cms.gov/NationalHealthExpendData/02_National-HealthAccountsHistorical.asp#TopOfPage
3 Centers for Medicare & Medicaid Services. Physician Fee Schedule (CY 2006) Final Rule. Federal Register (Nov. 21, 2005; 70116–70476). Web. http://edocket.access.gpo.gov/2005/pdf/05-22160.pdf
4 Centers for Medicare & Medicaid Services. Physician Quality Reporting System. Overview. Web. https://www.cms.gov/PQRS/01_Overview.asp#TopOfPage
5 Centers for Medicare & Medicaid Services. Medicare EHR Incentive Program, Physician Quality Reporting System and e-Prescribing Comparison (March 2011). Web. https://www.cms.gov/MLNProducts/downloads/EHRIncentivePayments-ICN903691.pdf
6 Porter, Michael E. and Elizabeth Olmsted Teisberg. Redefining Health Care: Cre-ating Value-Based Competition on Results. 2006. Harvard Business School Press.
7 Trapp, Doug. More States Expanding Their Move to Medicaid Managed Care. Amednews.com (May 30, 2011). http://www.ama-assn.org/amednews/2011/05/30/gvsb0530.htm
8 Pear, Robert. Medicare Plan for Payments Irks Hospitals. The New York Times (May 30, 2011). http://www.nytimes.com/2011/05/31/health/policy/31hospital.html?_r=1&ref=todayspaper
9 The Advisory Board Company. IT and Accountable Care—The Big Challenge Ahead: An Overview of the Mission and IT Requirements of Next-Generation Providers. HIMSS Senior IT Community Webinar (January 21, 2011).
10 National Committee for Quality Assurance. Patient-Centered Medical Home. Web. http://www.ncqa.org/tabid/631/default.aspx
11 Ibid.
12 Spencer, Gregory MD. How to Bring Patient Care “Back to the Future. Group Practice Journal (April 2010).
13 CIGNA’s Collaborative Accountable Care Programs Improving Quality and Reducing Costs. Business Wire (March 24, 2011). Web. http://www.businesswire.com/news/home/20110324005212/en/CIGNA%E2%80%99s-Collaborative-Accountable-Care-Programs-Improving-Quality
14 Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders: “time” to share the care. Prev Chronic Dis 2009;6(2). http://www.cdc.gov/pcd/issues/2009/apr/08_0023.htm. Accessed 10 Aug. 2011
For more information on NextGen Healthcare’s portfolio, and to view
initial product demonstrations, visit nextgen.com. To speak with a sales
representative, call 215-657-7010 or email us at [email protected].
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