John Sawyer, MD is an internal medicine physician at Hudson Headwaters, a federally qualified health center in upstate New York. The FQHC’s 150-plus physicians and mid-level providers care for a total of 50,000 patients over 320,000 visits each year. The practice, which uses Athenahealth’s AthenaOne platform, has fully attested to Stage 2 of Meaningful Use, and has been recognized as a patient-centered medical home.
What type of population health management program is Hudson Headwaters participating in?
I am trained as a primary care physician, but Hudson Headwaters provides pediatric and family care, as well behavioral health, women’s health, and dental care. In that way, you could say that we practice the essence of population health management for all of our patients; we’re managing their total health for a good portion of their lives, if not for their entire lives. We are also a patient-centered medical home, which means that we embody a primary care delivery model structured around coordinated, continuous, comprehensive, and community-based care. That’s a lot of “Cs,” but we believe in all of them!
As an FQHC, we are required by law to think about our population’s health. We are responsible for coordinating a patient’s care — from immunization to pap smears — even if we only see that person irregularly and for reasons outside of our control. Our funding is tied to this type of basic care coordination, and we have enormous reporting requirements that cover not only the kinds of care that we provide but also the quality targets we reach. Our cloud-based technology lets us drill down into that data to closely track and analyze our performance. We run population health campaigns using our patient engagement service, AthenaCommunicator, to identify and communicate with patients who are due for care and ensure that they come in to receive it. Hudson Headwaters also has an incredible team of care managers and outreach staff who identify high-risk patients for intervention and who generally ensure smooth care transitions. I credit a lot of their work to our excellent quality metrics. Our illness rates and average hospital and ER visits are quite favorable compared to other Medicaid blocks in New York State.
How has healthcare technology impacted HH’s population health management programs?
Healthcare technology has made coordinating care so much easier for our practice, and it’s made the experience of receiving care better for our patients. Hudson Headwaters has 16 geographically dispersed offices, ranging from Champlain, New York — one exit from Canada — to the central western Adirondacks. That’s over a two-hour spread. We staff outpatient facilities, two busy urgent care centers, and even inpatient facilities at several local hospitals. We work in nursing homes and offer home visit programs. Sharing paper charts between all of those care sites was virtually impossible before we implemented cloud-based health IT services. With them, our care teams are now able to communicate seamlessly. We can see the same patient in different offices, review their charts remotely, and respond to questions during off-hours via the patient portal. It’s a much more streamlined process, and one that has encouraged efficiency and patient engagement. Rural regions like ours historically struggle with patient engagement; having flexible technology that connects us to our patients outside the encounter has been essential.
What types of IT challenges do FQHCs face when it comes to implementing population health management strategies?
It can be quite difficult to get the cost data we need to build a really data-rich analytics model for our population health strategies. We look carefully at utilization, benchmark our providers and locations, and try to identify opportunities to increase quality while reigning in costs. But, we can never get all the data we need. Currently, we use a homegrown solution, running reports out of hospital discharge logs. We have started with our first imports of Medicare data with full cost information processed through Athena’s ACE population management system. It will allow us to define the sorts of care our patients are using and who the most efficient providers of service are. I believe that the transparency and network intelligence offered from cloud-based software will be able to satisfy our data reporting and analysis needs.
What plans does HH have for the next phase of its population health management projects?
Finances have traditionally been tight for FQHCs. It’s really hard to execute your mission when you have no margin, so population health incentives open up a whole world of financial opportunity for us. We need a solution that will unite all of our data with our outreach efforts, to automate tasks and reporting. That way, we can better prove the value we’re creating and get compensated for it. Currently, Hudson Headwaters lives with its feet split between the fee-for-service and fee-for-value world. We participate in a few pay-for-performance programs with private insurers and an ACO with Medicare Shared Savings Program. I anticipate that Hudson Headwaters will continue to compete in the fee-for-value world, as those opportunities continue to appear.
What are the biggest IT challenges HH faces at the moment? How will these be overcome?
Interoperability is a big and entrenched problem. Hudson Headwaters needs to be able to exchange health information with other care sites that treat our patients. Even though this exchange is technically possible, there are many economic and business disincentives in the industry that prevent it. Some of the fault lies with the big software vendors, who charge enormous fees to build technical interfaces with other vendor systems. And some of the fault lies with hospitals and health systems, who intentionally lock-in their data to control where patients are able to receive care and where providers are able to offer it. I believe that the free exchange of health information is best for healthcare overall, and I hope that in the future, we are able to meaningfully interoperate with all of the care sites that touch our patients.