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New skills, new tools and better care.
Transformation is frequently cited as a prerequisite for the creation of greater value in healthcare. We can envision what a better healthcare delivery model would look like, and we can see that current business logic and practices-which disguise costs as revenue, waste as scarcity and fragmentation as control-are so at odds with a sustainable healthcare system that sweeping transformation is essential. It is more difficult to understand how to make transformation occur-where to start, what to do, what’s most important and when (or if) it ever will end.
Three years ago, Rocky Mountain Health Plans (RMHP) and several partners in western Colorado began a region-wide transformation effort. We didn't have much insight about how to do the work or what to expect. We did, however, believe that success would entail the development of two things: new skills and new tools.
We also understood that data-driven processes are the basis of value creation in every other industry. Accordingly, we jumped at an opportunity announced in early 2010 by the Office of the National Coordinator (ONC) to demonstrate how technology could drive transformation on a broad basis. We were very fortunate to receive a Beacon Communities award.
Our Beacon plan was very simple:
This approach enabled us to get traction quickly, engage leaders and sustain momentum. Fifty-one practices-more than half the region’s primary care base-worked collaboratively to achieve agreed quality targets. We covered a wide area, which includes Grand Junction, Colo. and the surrounding seven-county region-a 17,500 square mile area with 320,000 residents.
By the end of the program, more than half the practices had moved on to more sophisticated objectives in care management and population health; nine practices are now participating in the Center for Medicare and Medicaid Services Innovation Center’s Comprehensive Primary Care initiative.
We know this process is replicable in other communities, because none of the ideas or techniques we adopted in our Beacon initiative were our own. We borrowed them from national thought leaders and other systems, and adapted them to our own circumstances. Further, the opportunity to expand Quality Health Network’s infrastructure occurred simply because the community-like several others around the country in a diverse variety of market circumstances-had already made a commitment to pool its own resources for a shared health information exchange.
Transformation requires more than “buy in.” Active leadership, daily work and routine course correction are essential.
Our Beacon leadership team included c-level executives from RMHP, the Mesa County Physicians’ IPA, Quality Health Network (QHN, the community health information network) and St. Mary’s Hospital and Regional Health System. Club 20, a western Colorado advocacy group, brought business and civic leadership to the table. This team met regularly to set goals, monitor progress and provide public support for the program.
But real change does not occur at 30,000 feet; it happens on the ground. Physician leaders and community organizations drove the Colorado Beacon program forward in daily practice; regular meetings with Quality Improvement Advisors (“QIAs”-coaches deployed by the health plan to assist practices with their process, data collection and measurement efforts) and at region-wide learning events. Four times a year, Colorado Beacon hosted Learning Collaboratives that linked participants’ activities across the region. These forums offered practical guidance and an opportunity for participants to compare measurements, resolve riddles and unlock functionality within their respective EHR systems. They shared setbacks and successes collegially.
All shared a vision: Improve each patient’s experience of care while being accountable for the health of the population as a whole. By connecting local leadership, organizational development courses and collaborative action, we created a self-sustaining momentum that will outlive the initial investments of time and resources.
Waiting is wasting. Had we waited for perfect measures, standards, interoperability and technology to become available, or imagined that a single platform would solve all of our problems, Colorado Beacon would not have happened.
Setting manageable objectives in real-world clinical settings enabled participants to get traction. In many cases, we moved forward with data collection, validation and feedback processes without the support of “certified” EHRs or sophisticated patient registries. We adopted Meaningful Use measures and other recognized standards rather than trying to reinvent the wheel. More importantly, each practice took ownership of its improvement process, setting its own quality improvement priorities.
We emphasized that data use and measurement are primarily intended to build new systems. The outcomes reflected in public reporting of the various metrics are valuable, but we did not administer them as ends in themselves.
Colorado Beacon practices improved dramatically across several measures of performance. In the short term, these measurements created meaningful feedback for the care teams, substantiating the relationship between measurement and improvement. They also positioned practices to adopt more sophisticated data use goals and measures of value over the long term.
A trained, community workforce is incredibly powerful. Technology is not enough; hands-on expertise, flexible teams and ongoing leadership are necessary to make data actionable.
Clinicians quickly became comfortable with activities beyond the scope of their established routines with the help of boots-on-the-ground coaching and broad-based skills development. Teams from RMHP and QHN assisted Beacon practices to work through a community wide process-improvement curriculum and assisted with the adoption and integration of technology.
As EHRs evolve from fee-for-service “billing machines” to tools that support measurement to advance health and cost accountability, new functionality is becoming available to support transformation. The Colorado Beacon workforce provided direct, technical assistance to help practices better understand what support already existed within their EHR platforms and how to modify clinical processes to take better advantage of it.
QIA visits to practices created trusting relationships that gave rise to insight and shared knowledge, while Learning Collaboratives spread this knowledge across the community. The resulting expertise formed human capital that will continue to grow and produce increasingly sophisticated opportunities for transformation over time.
Practice transformation, data aggregation and clinical analytics are all abstract concepts. Without specific examples of how technology can be used to drive improvement in daily clinical workflows and patient encounters, the big idea often remains just that-an idea.
So we focused on the deployment of a few, new applications in a small number of care settings. This approach enabled Colorado Beacon teams to work out kinks and learn how to be efficient in a safe environment. More importantly, it let physician leaders prove to themselves whether the technology lived up to its billing and then share positive experiences with peers. Using a flexible community workforce and deployment process, Colorado Beacon could respond effectively as demand for these tools grew in other practices.
This approach has accelerated region-wide deployment of sophisticated population management, risk stratification and patient activation tools including Archimedes IndiGO and the Advisory Board's Crimson Care Registry. Such tools-often accessible only to heavily capitalized, integrated health systems-are invaluable in targeting interventions to prevent adverse events and supporting behavior change outside the physician’s office. We have developed an Applications Steering process and a centralized Project Management Office to oversee the expanding number of applications interfacing and integration projects throughout the region. We are on target to have data for approximately 100,000 patients (one-third of the entire regional population) aggregated and modeled within these applications by the end of 2013.
Colorado Beacon was a success, but it was only a start. Transformation does not fit neatly into a three-year pilot or a simple pre-post evaluation scheme. What works today may have to be refined tomorrow. As practices move forward with new models of care delivery and reimbursement, both the rigor of the work and the participants’ stake in success become greater.
Collaborative measurement and learning processes within our Beacon initiative provided us with a glimpse of how transformation could be accomplished in Colorado. Likewise, the quantifiable value of improved health is becoming clearer in our population analytics, as is a sustainable budget to finance the work ourselves.
To succeed, we must create a culture and operating framework in which learning and improvement activities do not occur as “special projects” or “heavy lifts” outside the scope of normal daily activity. Continual learning, improvement and innovation is the work itself.
Patrick Gordon is the associate vice president of Rocky Mountain Health Plans.