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.”
- About Truman MC
- Cerner in acute & ambulatory
- Behavioral health in PC clinics — “Treating the whole patient”
- Making healthcare more “user-friendly”
- Recruiting docs to increase patient engagement
- MU as a barometer
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I think we’re all in a post-implementation optimization world right now. The need for data and more sophisticated ways for providers to get information and to be able to view information in the system continues to increase.
We are constantly working to provide better tools for our clinicians to be able to view populations so that they can ensure that those with chronic disease are getting their appointments on time, they’re getting their tests on time, and they’re doing all the things they need to do to keep themselves healthy.
We can make our own systems pretty complicated for a patient that may not be familiar with healthcare in general, and so we work hard to make it as user-friendly as possible.
If the physician engages with the patient in the ambulatory setting and really talks to them about using the portal in a way that’s meaningful for them, we find that we have more success.
We’ve been named Most Wired for several years and we’re at HIMSS Stage 7 on the acute care side. We use those as ways to really gauge ourselves as an IT department to know that we’re meaningfully using the technology to support better patient care.
Gamble: Hi Mitzi, thanks so much for taking the time to speak with us today.
Cardenas: I’m really glad to do it. Thanks a lot.
Gamble: So to get us started, why don’t you give us a little bit of background information about Truman Medical Center — what you have in the way of hospitals and ambulatory, things like that.
Cardenas: We actually have two hospitals. One is in urban core Kansas City, Missouri, and the other is about 15 miles out in an area called Lee’s Summit or Lakewood, Missouri. We have more than 600 beds, and we have about 51 clinics, both primary care and specialty. We also have a very large behavioral health component, so we see a lot of comorbidities with behavioral health patients as well as medical. We have about 400 employees and a gross revenue of about $750 million. We do a very large uncompensated care burden, about $130 million at our cost. So we are a safety net organization for this area.
Gamble: With the geographical area you’re in, I would think that there are probably a good number of competing hospitals and health systems in your neck of the woods.
Cardenas: There are. We have a pretty large healthcare presence in the community. We have some large hospitals and we have some other not-for-profits as well as for-profits. We are the only safety net organization or hospital system within the area, and of course we’re right on the state line, so we have Kansas healthcare as well as Missouri healthcare.
Gamble: I’m sure that makes for some challenges when you’re talking about being able to connect with those patients and physicians.
Cardenas: Yes, it does, although I think we’ve done a good job as a community to be able to create ways that we can connect. We’re starting to exchange information across the state line.
Gamble: Okay, and we will dive a little bit more into that, but just to give us an idea of the landscape, do you have practices that are both owned and affiliated?
Cardenas: We actually have employed close to 50 providers, including nurse practitioners, physicians, and psychiatrists, and then we work with a faculty practice plan. We’re an academic medical center and we’re affiliated with the University of Missouri Kansas City, and we have a faculty practice plan. Most of our physicians that practice here are part of that practice plan. We do have some community physicians as well.
Gamble: As far as the clinical application environment, you are on Cerner, correct?
Cardenas: Yes, we are. We’ve been on Cerner since probably the early 90s, with lab, radiology and pharmacy. We have been implementing Cerner Solutions for quite some time. We really executed our EMR, if you will, on the acute care site as well as the ambulatory site starting in early 2009. We are Cerner across almost all of our clinical applications, and then we have Philips PACS for radiology and cardiology and then we use a product called PsychConsult on the outpatient behavioral health side, although we are migrating a lot of their workflow on to Cerner as well.
Gamble: For behavioral health?
Cardenas: Yes, on the ambulatory side. For the inpatient, because we do have inpatient psychiatry beds, they use Cerner.
Gamble: That’s something where unfortunately across the country we’re seeing that there’s a lot of demand for behavioral healthcare but the supply isn’t quite there. Is that something that you’re dealing with just as far as long wait times for appointments, or just having to scramble to meet the needs of all the patients?
Cardenas: From a behavioral health side, we have a very sophisticated behavioral health practice, both on the outpatient and the inpatient side so I would say that in terms of the range of services offered for those that have a behavioral health diagnosis, we’re very sophisticated. We’re working very hard now to incorporate behavioral health providers into our primary care clinics so that we have the advantage of treating the whole patient. We do find that a lot of people in general have undiagnosed behavioral health needs, and so by having providers in our primary care clinic, those needs can be identified earlier. There’s some comfort in the fact that that provider is already in the setting.
Gamble: So now as far as the Cerner system, are you in constant post‑integration optimization mode? Are you looking for ways to further optimize the system?
Cardenas: I think we’re all in a post-implementation optimization world right now. The need for data and more sophisticated ways for providers to get information and to be able to view information in the system continues to increase. So we are doing a number of things that require significant amounts of data; for example, we’re working to be NCQA-recognized in all of our primary care clinics as patient-centered medical homes. We’ve also been working with CMS innovation grant to look at targeted zip code areas of the community that have very high costs of care — patients that frequently enter the ED and are in significant need of care by the time they enter the ED. We’re looking at those populations with the CMS grant and had some extremely good results. We’re very focused on chronic disease management. We are constantly working to provide better tools for our clinicians to be able to view populations of people so that they can ensure that those with chronic disease are getting their appointments on time, they’re getting their tests on time, and they’re doing all the kinds of things that they need to do to keep themselves healthy.
I think we’re all not only in a post-implementation mode with our EMR and continuing to need to grow that, but we’re also working on extending technology out to our patients. And so we’re very focused on connected health, on top of all the great things like ICD-10 and Meaningful Use Stage 2, and all the other exciting opportunities we have to continue to give ourselves job security. I think that it’s a good time to be in healthcare IT, as it has been for the last few years.
Gamble: Absolutely, there’s so much going on. You talked about chronic disease management. That’s something that’s really coming to the forefront at a lot of organizations. Can you talk a little more about the grant?
Cardenas: It’s one of CMS’s innovation grants that really looks at high-cost zip codes, primarily in the urban core. We’ve had some significant benefits in working with those smaller subsets of patients to really impact their health — tremendous financial and clinical benefits. It’s been pretty amazing.
Gamble: For these patients, I guess they have to have some sort of device at home and some sort of connectivity to be able to report certain information.
Cardenas: It’s both — some in the home, but also, from a non-technology standpoint, it’s being able to identify those patients and see where they are in their journey on the technology side. And then on just patient care side, it’s really sort of a high touch. We work with those patients to ensure that their health literacy continues to grow and that they have the tools they need to be successful, both by self‑managing as well as having our providers helping them on an individual basis.
Gamble: How is it determined, which patients you reach out to? I know you said you have targeted zip codes, but is it just a sample of patients?
Cardenas: In general, when we started working with a very focused chronic disease management effort, and, I would say, a service delivery effort, that was a few years ago. And we really looked across our patient population — those who were coming into the ED that were challenged, that we were seeing repeatedly that had challenges with managing their diseases, getting their medications, and really understanding what they needed to do with their medications and their treatment. And so prior to the grant, we had some great opportunities to use the data that we had to identify and reach out to a population or subset of our entire population of patients.
Gamble: And you’re finding that patients are willing to get involved a little more in their care?
Cardenas: I think they are. I know they are. Health is a goal for most of us, and certainly these people really want to do what they need to do. They oftentimes would have financial challenges or challenges understanding of what kind of care that they need to receive. They also have access issues; sometimes transportation is challenging. There are other reasons why it can be challenging to come and seek the kind of care that keeps you healthier and doesn’t land you in the emergency department when things have gone really wrong. And so we’re looking at opportunities to receive medications at a cost that you can afford, and all of those things that play into the picture.
A lot of it sometimes is a concern about coming into a healthcare institution because of not really understanding the system. We can make our own systems pretty complicated for a patient that may not be familiar with healthcare in general, and so we work hard to make it as user-friendly as possible.
Gamble: Have you seen a difference or a reduction in either readmission rates or emergency admissions for patients that have conditions that could have been prevented?
Cardenas: Yes, we’ve seen some really great results in all those areas. I think a lot of us are focusing on chronic disease management because unfortunately we have a lot of chronic disease across America. But we’ve seen some really good results.
Gamble: I know that that’s something that’s going to be really of interest to our readers because it’s an area that so many people are getting more involved with now, especially with the Meaningful Use 2 requirements. But then also it’s about trying to create a better health system, and one of the best ways to do that is to get patients more involved in their care.
Cardenas: Exactly. I think we have some great opportunities with low-cost technology to be able to do that and keep them engaged on a daily and almost moment-by-moment basis.
Gamble: Do you have any patient portals at this time or any plans to do that?
Cardenas: We do have a patient portal. We rolled it out about a year ago. What we’re doing now is really refocusing our efforts on how to better market it and trying to add incentives so that people will use it. One of the things we found is that if the physician engages with the patient in the ambulatory setting and really talks to them about using the portal in a way that’s meaningful for them, we find that we have more success in getting patients to use their portal for a variety of things. We’ve got a very refocused effort on trying to look at our portal and make it meaningful for our patients, and really to fit in to their lifestyles with their chronic diseases, or just in their lifestyles in general. It’s really becoming more of a part of our chronic disease management.
Gamble: Where do you stand with Meaningful Use?
Cardenas: We attested to Medicaid — adopt, implement and upgrade — as soon as we could. We are now Stage 1 Meaningful Users on the Medicare side, and most of our providers are as well. We’re pretty close to being ready for Stage 2 and believe that we will be ready in time to attest and just continue to grow and build in that area. We use Meaningful Use as a barometer for how successful we are with the use of technology, just like the other things that we have achieved. We’ve been named Most Wired for several years and we also are at HIMSS Stage 7 on the acute care side. We use those as ways to really gauge ourselves as an IT department to know that we’re meaningfully using the technology to support better patient care.