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Payment Rules are Changing. Are You?


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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?

  1. 1. Payment Rules are Changing. Are You?
  2. 2. I t 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.
  3. 3. This time the change is for real. Quality reporting initiatives are rapidly evolving into true pay-for- performance programs. Solutions for: Ambulatory | Inpatient | Community Connectivity | Performance Management | Consulting Services
  4. 4. F or 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.
  5. 5. Making “value” the watchword M edicaid 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.”1 Having 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.
  6. 6. Required: System-wide redesign P rominent 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:
  7. 7. True quality care demands visible patient data among all stakeholders— facilities, providers, and patients...
  9. 9. T he 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
  10. 10. The next step: “accountable” care models A ccountable 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 care As 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.
  11. 11. Providers actually share with the payer the financial value gained from population management.
  12. 12. D iscrete 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.
  13. 13. Take, for instance, our unique automated patient outreach: NextGen Population Health I ntegrated 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
  14. 14. 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 Exchange NextGen® 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: BY 1. Denominator 2. Numerator 3. Exclusion parameters 4. Treatment opportunity
  15. 15. NextGen Patient Portal While 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.
  16. 16. SOLUTIONS IN ACTION Five 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…
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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 Physicians Six-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.
  21. 21. 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
  22. 22. 1 OECD Health Data 2010. How Does the United States Compare. Web. http:// 2 Centers for Medicare Medicaid Services. National Health Expenditure Data. NHE Summary Including Share of GDP, CY 1960-2009. Web. http://www. asp#TopOfPage 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. 4 Centers for Medicare Medicaid Services. Physician Quality Reporting System. Overview. Web. 5 Centers for Medicare Medicaid Services. Medicare EHR Incentive Program, Physician Quality Reporting System and e-Prescribing Comparison (March 2011). Web. 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. (May 30, 2011). gvsb0530.htm 8 Pear, Robert. Medicare Plan for Payments Irks Hospitals. The New York Times (May 30, 2011). html?_r=1ref=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. 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). Accessed 10 Aug. 2011
  23. 23. For more information on NextGen Healthcare’s portfolio, and to view initial product demonstrations, visit To speak with a sales representative, call 215-657-7010 or email us at Copyright © 2013 NextGen Healthcare Information Systems, LLC. All rights reserved. Patent pending. NextGen is a registered trademark of NextGen Healthcare Information Systems, LLC. All other names and marks are property of their owners. CCHIT Certified® is a registered mark of the Certification Commission for Health Information Technology. The Trademark BlackBerry® is owned by Research In Motion Limited and is registered in the United States and may be pending or registered in other countries. NextGen Healthcare is not endorsed, sponsored, affiliated with or otherwise authorized by Research In Motion Limited. IBM and Cognos are trademarks of International Business Machines Corporation, registered in many jurisdictions worldwide. BRO-00026 1-10/13