Leveraging Technology to Power Transformation in Today's Healthcare Environment Healthcare executives, staff and clinicians consistently say they are both surprised and impressed at how new technology has disrupted the industry. As policymakers, payers and consumers impose higher standards on healthcare systems, including value based reimbursement strategies, hospitals and health systems are under pressure to change workflows, clinical decision-making, and, importantly, how care managers maintain communication with patients throughout the continuum of care including transitions after hospitalization. One key to making these shifts is the incorporation of various technological tools and systems into day-to-day operations. For instance, technology is an efficient enabler of communication and coordination between members of the healthcare team. The vast majority of healthcare professionals 95 percent believe successful care coordination leads to reduced readmissions, according to the results of a survey by PerfectServe and Harris Poll. Additionally, 90 percent of survey respondents said investment in sophisticated data analytics is necessary for effective communication. While virtually all healthcare workers understand the need to employ interdisciplinary team communication and clinical decision-making support tools within population health management efforts, problems with the software traditionally used for this purpose persist. Finding solutions for workflow management and decision support Care management software used by many payers is not well-suited for provider-led care management. It often is expensive, complex and lacks clinical protocols, according to xg Health Solutions, a national healthcare solutions company launched in 2013 by Danville, Pa.-based Geisinger Health System. Additionally, tools designed by payers often lack evidence based, condition-specific assessments, automated care plans guided by the patient s status and workflows that support care manager activities. "Care management systems need to help care managers prioritize their work on any given day and provide impactful scripting to drive clinical improvements," says Melodi Brown, RN, MSN, CCM, vice president of care management at xg Health Solutions. "Care managers often don't know the relevant evidence to ask the questions to support patient needs. You can engage a patient and not ask the most critical questions or address key topics based upon risk stratification. xgcare helps prompt care managers with impactful content while they are engaging with a patient." xgcare, a care management program from xg Health, is driven by the experiences of the company's expert clinicians. xgcare contains built-in workflows for assessments and
care plans, as well as patient health education and self-management plans and automated task prioritization. Data analytics is another valuable tactic hospitals and health systems use to inform clinical decisions and determine which patients require a higher degree of follow-up care after they are discharged from the hospital. According to a HealthLeaders Media survey from April 2015, just under half of healthcare organizations currently use analytics to track population health, but that number will reach nearly 80 percent by 2018. Nearly three-quarters of the survey's 8,000 respondents reported plans to begin or increase investments in the quality of their data in the next year, and 52 percent pointed to overcoming insufficient skills in data analytics as a top strategic priority, according to the survey report. Population segmentation, an analytic and clinical process "We use a two-step process to identify and then segment the population on whom we focus," says Ms. Brown. xgcare uses predictive modeling and risk stratification to assess the population, and program also covers a vast range of clinical content and organizes information in a way that supports team-based care. Predictive modeling The first step we use in xgcare is predictive modeling to identify the highest risk, most complex patients. Factors that we consider include patient demographics, clinical conditions, utilization and gaps in care. Risk stratification The second step of our population segmentation process relies on clinician judgment of a patient's status. Based on case managers' patient assessments, they can use real-time information on patients' conditions to make care management decisions. For example, say a patient is categorized as low risk. If they are not adhering to the medication and/or treatment regimen, or do not have access to other necessary resources, they can immediately be switched to a high-risk level and receive more intensive care management services. A two-step risk stratification process helps leverage the power of predictive modeling with real time patient assessment information. Breadth of clinical content xgcare includes structured assessments for major chronic conditions, which then drive work flow, action plans, self-management plans and correspondence on an automated basis. Team-based care support Another important aspect of care management is coordination and communication among the whole clinical care team. The xgcare platform supports team-based care by organizing patients' information for various clinicians to view. Team members can see
biometric data, claims information and recent assessments, giving the care team a 360- degree view of patients. Communication is a key requirement for team-based care, on which successful population health management depends. With effective communication, each clinical team member can operate at the top of his or her license, which ensures the team's time and clinical expertise is well spent. Easing the transition through education Population health management, the underpinning of value-based care, requires each member of the care team including case managers, social workers, physicians and nurses to obtain new knowledge and skills. Each needs "to know what to do to help the patient. To do that, they have to be trained adequately so they can be proactive, not reactive," says Joey Sevison, RN, vice president of population health management at xg Health Solutions. The incorporation of new practices and processes into clinicians' and other workers' workflow is a significant adjustment that requires time and education. xg Health's learning solution, xglearn, helps healthcare organizations accelerate training for both clinical and nonclinical staff to better prepare them for population health management. xglearn combines coaching and online content produced by Geisinger and xg Health experts with immersion in a healthcare facility where experienced staff are working. "The combination allows nurses and others to learn so they can hit the ground running so their critical decision-making skills are really honed and they are ready to roll in the clinical environment," says Ms. Sevison. The training program, most of which is online, is highly interactive. Students watch videos of experts addressing real-life challenges and complete short quizzes related to what they've seen. Various interactive scenarios help trainees make decisions and define priorities for an individual or group of patients. The virtual patients who trainees treat via xglearn present behavioral and social issues to better reflect real-life cases. Trainees through xglearn have the chance to utilize best practices for care management from experts at Geisinger who have devised those practices over decades. "The nice part is the experts share what works, and importantly, what doesn't work it saves others from the pain and suffering of discovering that on their own," says Ms. Sevison. "Anyone can go online and find a care management training course and hope it will help. However, you really have to ask certain questions before investing in online education. Will the program be relevant to what you're trying to accomplish? Will trainees walk away actually knowing something different?" Optimizing EHRs with supplemental technology
EHRs have become the mainstay of hospitals' and health systems' patient medical records. However, there is room for improvement. Four in 10 healthcare professionals do not think EHRs are sufficient for coordination, according to the PerfectServe survey. Of this group, 53 percent of nurses and care managers said EHRs are not adequate for effective communication with physicians. Without efficient means of communication, population health management efforts could be significantly stunted. "EHRs are designed as transactional systems that facilitate administrative tasks, such as scheduling, ordering and billing. They are not as efficient at supporting clinician workflows," says Marcy Stoots, DNP, RN-BC, general manager of EHR apps for xg Health. "As a nurse, I know clinicians are always on the hunt for more information." Geisinger has spent nearly two decades customizing its EHR to simplify workflow, increase efficiency for physicians and facilitate compliance with evidence-based practices. Now Geisinger is making these tools available to others through xg Health's EnrG suite of software apps. These apps, which use the SMART on FHIR platform, can be used with desktops, laptops and tablets. The apps extract and analyze data in real time, then reorganize it and present it to clinicians in a user-friendly way with decision support, without any toggling between screens. The apps focus on management of common chronic diseases, procedures and potential complications associated with them. "We are not looking to replace EHRs, but rather to supplement them," says Earl Steinberg, MD, CEO of xg Health Solutions. "These apps and workflows have existed at Geisinger for a long time. However, until SMART on FHIR, we didn't have a way to take them out of Geisinger and bring them to other places." The EnrG suite of apps addresses many of the concerns and frustrations physicians and nurses have expressed about EHRs. For example, it makes it easier to find data within EHRs and organizes it in a clinically logical, user-friendly way. The apps also assist in production of a note, which saves clinicians time, according to Dr. Steinberg, who additionally serves as Geisinger's executive vice president of innovation and dissemination. The apps are also preconfigured with Geisinger's best clinical practices and clinical decision support, which increase the likelihood of physicians making the most clinically appropriate decisions for each patient and also reduces the time required to do so. The tools increase the amount of time physicians can spend in face-to-face interaction with patients during an encounter as well. Seventy percent of physicians reported a decrease in the amount of face-to-face time they have with patients since introducing EHRs into their practices, and 27 percent said EHRs decrease their ability to respond to patient issues, according to a 2014 Medscape survey.
"When I go to my doctor, he sits there and types the whole time there is no interaction with me, the patient," says Dr. Stoots. "In this regard, EHRs interfere with the visit. The EnrG apps automate a large portion of an encounter note, saving clinicians time from a documentation perspective and engaging patients in the process." Leveraging technology such as xgcare, xglearn and the EnrG suite of apps to guide population health management programs completes a "three-legged stool," consisting of processes, people and technology. These three elements, in combination with support from leading experts, can accelerate organizations' progress on the path toward improvement and optimization, according to Dr. Steinberg.