When it comes to population health management, Truman Medical Centers is “thinking outside the bed.” What that means is looking beyond the care provided within the four halls of the hospital and relying on strong community outreach programs to increase patient engagement and improve health. In this interview, Mitzi Cardenas talks about the work her organization is doing to target chronic disease management — whether it’s through IT tools like portals, or more rudimentary vehicles like mobile farmer’s markets. She also discusses the organization’s EHR journey, why they’re opting for a “build-your-own” ACO, the governance team she helped put together, and why her team views achievements such as Stage 7 “as a barometer.”
- Keeping ACOs local
- Partnering with payers
- “Thinking outside the bed” with community outreach programs
- Mobile markets & food desserts
- “Getting to the core of chronic diseases”
- LACIE & MO Health Connection
- Demonstrating the benefits of IT — “It’s not just checking a box.”
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Ideally, we’d like all of our providers to use the electronic record as a tool to educate the patient when they’re there so they can see what’s happening and they can visualize it.
We do what our CEO calls thinking outside the bed. It’s focused on trying to not just think about what’s happening within the four walls of the hospital, but really getting out and reaching out to the patients.
With some of those more basic things like the designated food desert in our urban core, certainly we’ll apply technology on top of that at some point where we have an opportunity.
We are patient-centered medical home. The NCQA recognition and continued development of that has a big data component. There’s a lot of IT and technology involved with ensuring that is successful.
Before we do new work, we always have to be able to demonstrate not only a return on investment, but how it is really impacting clinical care — why are we doing it besides just checking a box and saying, ‘okay we did that, we’re moving on.’
Gamble: In terms of Stage 2, what have you found to be the biggest challenges?
Cardenas: I think the biggest challenge is going to be around the use of the Personal Health Record and what’s required there. Most of the criteria we had been moving forward on anyway, and in terms of meeting percentages, we had far exceeded many of those. So I think tracking of some of the things and just really ensuring we can engage our patients appropriately to meet those new measures is probably going to be the biggest advantage to us, and having something that pushes us in that direction is going to be helpful. But I think it’s going to be a challenging piece of work to measure ourselves and make sure we’re continuing to do that.
Gamble: It seems that one of the real challenges with patient engagement is the fact that it’s difficult to control. You have to reach out to this group and try to get them engaged, but it isn’t necessarily something that’s within your control. But I think what you’re doing by going to the physician practices and starting at that level to get patients into the portal — things like that seem to be a good way to open those doors a little bit.
Cardenas: That’s what we’re hoping and it’s what we believe to be true. We’ve seen some good results and have heard of good results when the provider gets engaged. Ideally, we’d like all of our providers to use the electronic record as a tool to educate the patient when they’re there so they can see what’s happening and they can visualize it, and also to be able to communicate with them or to provide them information through their portal. I think when that’s done from the provider’s vantage point, the patient sees it differently than when you just say, ‘go home and click on this link and sign up for this.’ We believe that’s going to be one of the most successful ways to do that.
Gamble: Are you involved in any accountable care organizations at this point, or do you have plans to go in that direction?
Cardenas: We really don’t — not at this moment. We are doing some direct employer contracting. We also are looking at opportunities within our own employed population. We have a very extensive wellness program internally. We are really looking into partnering with payers in different ways, knowing that they have the experience dealing with risk and we have the delivery experience. We’re trying to look at some more unique opportunities. So again, direct employer contracting is one of the ways that we’re engaging outside the organization.
Gamble: It seems like something that you have to customize based on your patient population. You mentioned that you’re a safety net organization, so it seems to me that how you decide to reach out and form any collaborative organizations really has to be based on the type of patients you deal with the most.
Cardenas: That’s true and obviously our growth is in a variety of different payer mixes, so we have kind of a different population at one hospital than the other. We do what our CEO calls thinking outside the bed. It’s focused on trying to not just think about what’s happening within the four walls of the hospital, but really getting out and reaching out to the patients. We have a very strong and viable community outreach program. We’re out in the communities all the time. We’re working with the churches. We’re working with community and civic leaders. We have a farmer’s market, for example, that we do at both locations in the warmer months that provides fresh fruits and vegetables to the communities. We also have a mobile market that goes out to a number of locations in the urban core that takes fresh fruits and vegetables on a converted city bus, and we’re building a grocery store.
So from a population health perspective, we’re looking at making the community better — really getting to the core of some of our chronic diseases and providing the kinds of basic nutrition that people need and have challenges getting in a lot of areas. This is going to be an important way to do that. So we’re doing some kind of innovative things in the area of community outreach and community and population health.
Gamble: I think it’s interesting how in some ways you’re leveraging technology to improve health, but then in other ways, like you said, you’re going more to the core and helping to provide produce for people who don’t have easy access to it. It’s a combination of different approaches.
Cardenas: That’s true, and I think that’s important. A lot of these things that we’re doing just in general nowadays — the food part aside — we couldn’t really do if we didn’t have technology to support it. But with some of those more basic things, like the designated food desert in our urban core, certainly we’ll apply technology on top of that at some point where we have an opportunity. We’re thinking futuristically about where we can work with patients to be able to know what their health status is and what kinds of fruits and vegetables they should be eating via some kind of technology. I think is going to be kind of a cool thing to do that we look forward to have an opportunity to explore by virtue of the other work that we’re doing.
Gamble: That’s really interesting. There are a lot of possibilities on that front. Now in terms of health information exchange, are you involved in any regional or statewide HIEs?
Cardenas: We are. We’re involved in a regional group called Lewis and Clark Information Exchange (LACIE). It focuses on the Kansas City area and the hospitals and the health partners around the area. We’ve moved the dial on that communication pretty rapidly. I was also involved for several years with the statewide health information exchange, Missouri Health Connection. I worked as the co-chair of the technology and operations committee — building out the strategy for that and then also building up the operational plan for that. That was pretty exciting work. It was an opportunity to work with people across the state to really bring to bear the beginnings of a statewide exchange. We have a few local regional entities that will eventually connect to the statewide exchange.
Gamble: So the idea is to focus first on the regional exchanges and just getting those up and running and then to a point where they’re pretty sustainable.
Cardenas: Yeah. The statewide exchange is growing also. For Truman’s purposes, and just because of our local partners, this HIE was moving along and was further along, so it was a good opportunity for us to get in on something. A numbers of our partners in town had already made some decisions to move that direction. So we’re focusing first locally and then looking at the broader states because we’re sitting around the boarder, so we work with Kansas as well as Missouri, and the LACIE group is very well positioned to move in both directions.
Gamble: Are you still involved with Missouri Health Connection as far as the HIT committee?
Cardenas: No, I haven’t been for probably a little over a year. I had done that work for some period of time, and because of some other changing job responsibilities, I’m more focused on the local group. I sit on the LACIE board and I’m on the executive committee. With the changing priorities with my particular role, it’s just a little bit easier to work with our local group. And since that’s where our focus is right now, it makes a lot of sense for us.
Gamble: Right. Obviously, you have a lot going on. Are there any other major projects on your plate or big priorities for the next year or so?
Cardenas: In terms of IT, certainly ICD-10 is a big priority for everybody. It’s a big thing that we’re all focused on and most of us, I think would say, are concerned about. And again, we are patient-centered medical home. The NCQA recognition and continued development of that has a big data component. There’s a lot of IT and technology involved with ensuring that is successful. And we’re working on our connected heath strategy, really trying to get all the pieces and parts of that where we’re connecting with our patients and getting them engaged; getting that more into a strategy that’s very clear and concise. Just in general, there are continued needs for a number of things.
When I first got here in early 2008, we built a really strong governance program. Our governance group for IT includes all the senior leaders of the organization. They’re very committed to working with us and helping us prioritize the things that need to be prioritized from an organizational standpoint.
The other thing that we have gotten pretty crisp at is being able to track and demonstrate the benefits that we’ve gotten out of the work that we do. As part of our project management methodology, before we do new work, we always have to be able to demonstrate not only a return on investment, but how it is really impacting clinical care — why are we doing it besides just checking a box and saying, ‘okay we did that, we’re moving on.’ And so we’ve continued to track those benefits — both clinical and financial — and talk to the organization on an ongoing basis, as well as to our board.
Gamble: I like what you said about making sure that you’re not just checking the boxes, especially when you know there are so many projects that need financial resources and human capital. I imagine it’s really important to really be able to take the time to show the difference that these initiatives are making.
Cardenas: Absolutely. One of the objectives when we first started our really focused EMR implementation efforts in early 2009, when we were going to our board and asking them for the funding, was to be able to show them the benefits and not just say, ‘This is the timeline and this is when we’re going to achieve it, and at the end of this we’re going to check this box and say we did it.’ Now that in and of itself is a pretty big deal, but the really bigger deal is how we’re impacting clinical care. Are we reducing medical errors? We use some performance improvement tools from Cerner that help support us in reducing pressure ulcers, falls, and other things like that. Those are the types of benefits we can present both from the clinical side as well as certainly the financial side. That was a new way for our board to look at IT work, but certainly it made it more relevant to the organization overall especially based on the expense of an electronic medical record.