Bridges Health Partners is a Medicare Shared Savings Program accountable care organization. It was formed in 2017 and comprises four independent, non-profit health systems in the Pittsburgh metropolitan market and surrounding communities: Butler Health System, Excela Health, St. Clair Hospital and Washington Health System.

THE PROBLEM

The organization was interested in assimilating employed and affiliated independent ambulatory provider groups focusing on quality and outcome improvement throughout the integrated, regional care network.

“We had four health systems that shared common approaches to providing high-quality healthcare come together to form a clinically integrated network to deliver on accountable care organization and other value-based contracts,” said Dr. Robert Zimmerman, chief medical officer at Bridges Health Partners.

"Previously, care teams would need to go to multiple sources to find that information, which is inefficient and costly from a time perspective."

Dr. Robert Zimmerman, Bridges Health Partners

“Issues we had to overcome were that we were using nearly 20 different electronic health records vendors across our network. We wanted to be better together, find economies of scale and bring multiple data sources together to get a universal view of our patient populations.”

Bridges Health Partners also was looking for a scalable population health analytics platform to be its single source of truth where everyone in the organization would be using the same data when making business or care decisions with the goal being that the organization would be providing better patient care.

“The population health system we were looking for needed to be able to be EHR- and data-agnostic, allow data aggregation, provide condition registries, provide high-level reports regarding quality and utilization metrics, provide actionable data to identify and close care gaps, and risk-stratify population to help the care management teams allocate resources to the patients who will impact outcomes most,” Zimmerman explained.

“The system also needed to be able to customize initiatives – patient cohorts – and quality metrics to contracts we engage in, ingest and analyze paid claims data from Centers for Medicare and Medicaid Services and the commercial health plans, aid in reporting to CMS regarding ACO performance, and be our single care management platform,” he added.

PROPOSAL

Bridges Health Partners engaged with multiple vendors in its health IT set-up, of course, but the vendor that emerged on top for this population health effort was NextGen Healthcare Population Health, formerly known as EagleDream Health.

“We decided on several must-haves, including the ability to roll up quality metrics, deliver multiple views on gaps in care, and resource utilization that would impact shared savings, all of which would help move us away from fee-for-service toward value-based care,” Zimmerman noted. “We decided to choose several of the most important must-haves and start there.”

This system met nearly all of the organization’s needs right out of the box; the two exceptions being an EHR-agnostic care plan management platform and CMS-qualified registry reporting tools, which the organization decided would be implemented later.

“Additionally, Dr. Betty Rabinowitz, NextGen Healthcare’s chief medical officer, understood what tools are important to deliver on our mission and partnered with us to customize and optimize a solution that would allow us to provide optimal patient care in the value-based world,” Zimmerman said. “Dr. Rabinowitz brought to us the clinician perspective, as well as the tools to create what we needed.”

In total, NextGen Healthcare provided an easy-to-follow system with an intuitive user interface and multiple ways to visualize data, he added.

“This itself was a big win, and served multiple users, for example, the Bridges team, health systems, physician/hospital organization and care teams,” he explained. “Prior to purchasing the solution, a striking feature was how nimble the system is; and that the NextGen Healthcare team was interested in forging a true partnership, beyond simply being a vendor. The team truly wanted to help us achieve what we were trying to accomplish.”

MARKETPLACE

There are many population health system vendors on the health IT market today, including Allscripts, CareEvolution, Cerner, Elekta, Enli Health Intelligence, Epic, GSI Health, Health Catalyst, HealthEC, Innovaccer, MAP Health Management, Medicity, NextGen Healthcare, Optum, Orion Health, Varian Medical Systems and ZeOmega.

MEETING THE CHALLENGE

The concept of population health management is a process. Populations need to be identified, and to do that, a registry must be available. Through the registry, providers can readily see what care is needed, for instance, which patients have received care – and which have not – while identifying care gaps and presenting the data in a manner to help a healthcare organization take action.

“With our Population Health system, we can risk-stratify identified populations, identify care gaps, view what is needed, conduct monitored utilization, utilize patient pre-visit planning, manage transitions of care, direct care coordinator outreach, and plan campaigns throughout the year,” Zimmerman said. “We can see what appropriate care is missing and engage patients to partner with their care team to optimize their health.”

Bridges Health Partners used the predictive analytics tool to identify high-cost/high-risk populations, meaning that it could both retrospectively look at high-spend and prospectively look at the probability of high-utilization in the future, based on a high-risk scoring algorithm, he continued. The organization then could engage this population in intense outpatient management to identify opportunities to improve care and utilize the most appropriate resources, he added.

With value-based care, the aim is high quality, good patient experience and ensuring cost-effectiveness.

“Our Bridges staff, including the population health team, analysts and leadership, utilize the solution, and within our health systems, our physician/hospital organization leadership and local quality teams are users, as well,” he said. “We have an educational rollout planned over the next three-to-four months and aim to roll this out to all of the practices. Additionally, our goal is to have a ‘super user’ at all primary care locations and practices as we continue the rollout.”

RESULTS

The Bridges Health Partners MSSP ACO is producing huge savings: $8 million in its first performance year in the MSSP. It achieved this in part using the population health analytics.

For Bridges Health Partners, one objective is to measure and manage high emergency room utilization. Often, these issues can be managed at a more appropriate level of care if patients are engaged with their care team.

“We also have looked at readmission rates and taking advantage of the timely post-hospital visit to reduce these rates,” Zimmerman said. “By managing care transitions, we can move from more siloed care to more longitudinal care.”

Another objective is pre-visit planning. The organization can look a week or more in advance and care teams can plan for upcoming patient visits, determining ahead of time what patients will need.

“Previously, care teams would need to go to multiple sources to find that information, which is inefficient and costly from a time perspective,” Zimmerman explained. “NextGen Population Health provides all of that data using one source and one dashboard.”

In both the clinically integrated network and ACO populations, managing transitions of care is extremely successful in getting patients reengaged with care teams after discharge from a hospital, usually six-to-12 months, he said. Care coordinators can see care gaps and engage patients, recommending annual screenings or wellness visits, and identify patients who have not seen the care team, he added.

“Additionally, we can direct care coordinators to reach out to patients who have not been seen in six-to-12 months to maintain the most appropriate and optimal care,” he said.

ADVICE FOR OTHERS

There are several things to keep in mind when choosing a population health system, Zimmerman advised:

• Most important, the data must be actionable – to take to care teams – which then can provide the best care to the patient.
• Conduct research and familiarize yourself and your team to be clear on the mission and goals; be aware of your constituents; be clear on the end users.
• Decide which IT gaps you are trying to fill, and keep in mind what you need. Look at the existing technology and select technology that will integrate well with the existing infrastructure(s).
• Start the vendor meeting with a list of needs – do not wait for the vendor to suggest what you need, and look for a vendor with a reliable, honest reputation that can develop into a solid, trustworthy business relationship.
• Lastly, always keep the patient as the first priority using tools that provide the right care, in the right place, at the right time.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com
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