The following blog by Alliance Cancer Specialists CEO Ann Marie Edwards is based on her interview with the Association of Community Care Centers about using HealthEC’s population health management suite. The interview was published February 13, 2018.
Recognizing value-based models as the future direction of health care, Alliance Cancer Specialists began a population health management (PHM) journey in 2016.
Alliance, the largest community oncology practice in southeastern Pennsylvania with 21 oncologists in 11 locations, realized that improving outcomes and reducing costs for cancer care episodes required a comprehensive understanding of each patient’s entire healthcare experience. To manage outcomes reliably, we also needed to understand care delivered outside the network (tests, procedures, specialty providers, etc.), home care and long-term care services, and prescription fulfillment activities, to name a just a few.
Finally, to drive fully informed decision-making, Alliance physicians required a thorough understanding of co-morbid conditions and other encounters (e.g., a recent foot or bladder infection) that patients may not have mentioned to their oncologist, believing them to be irrelevant.
Without comprehensive data, we found it challenging to make holistic decisions about care, and to identify high-risk patients who may require more intensive management throughout their treatment. The practice also struggled to compare quality and cost variation that respected the severity of illness across a physician’s patient panel.
By integrating claims and pharmacy fulfillment data with the information in our electronic health record (EHR) we were able to create a complete longitudinal record for each patient and analyze data to identify gaps in care, which helped drive individualized care planning activity. And most importantly, these data were available on one centralized platform with an easy-to-navigate dashboard display.
Further, by implementing a population health management platform to support our efforts around the Center for Medicare and Medicaid Innovation’s Oncology Care Model, a value-based care delivery process is emerging at Alliance Cancer Specialists. The practice can now identify patients by stage, highest clinical risk, most frequent use of ER and hospital resources, and prescription fulfillment activity—even patients with high-cost care for non-cancer co-morbidities.
Breaking down the walls between the EHRs, health information exchanges, and hospitals and lab systems has provided a comprehensive picture of individual patient care. Risk stratification within the patient population has helped us focus attention and resources appropriately. Further, our connection to the health information exchanges provides daily notification of admissions, discharges, and ER visits so that we can better manage transitions of care.
Alliance Cancer Specialists now ensures that the sickest patients garner greater attention from care navigators and clinical staff, are seen more often in the office, and receive coaching on symptom reporting and management.
Every practice has to choose a starting point to embark on the journey to value-based care and for us it has been using patient-centric analytics to bring an individual’s needs into focus and to streamline efforts in the most meaningful way. It is a journey and we are early along the path to having these actionable analytics to inform care decisions but aligning value and quality is finally well within our reach.