Update #1 - Explore or expire: The joint mission of Sutter Health and Orion Health
By Jason Free, Features Editor, June 20, 2014
Suzanne Cogan introduces HMT’s exclusive Orion Health’s Living Case Study series in our May 2014 issue with a simple question: What is population health management? On the surface, her piece reads like any well-written thought leader feature found in many industry publications. She discusses a highly hyped, somewhat abstract practice, in this case population health management, and then proceeds to break it down into practical terms and calculations in such a manner that many in her field would state “the author did a great job” explaining an ambiguous trending concept. However, a closer examination shows that Cogan’s piece is not just the result of her strong composition skills, but rather Orion Health’s lengthy history of seeking new strategy models for healthcare organizations around the world.
My career has been rooted in the field of education, which shares the same ultimate objective as healthcare: to encourage positive changes in an individual and, in turn, in a broader population. Many outside academics do not understand that the pop culture mantra of “publish or perish” is a misnomer in terms of the proper path toward becoming an effective teacher. While it may be impressive to a layperson, the act of publishing is simply an act of proclamation. Anyone can proclaim anything, and if the act of proclamation is chased for the sake of being chased, words become not only hollow but completely absent of meaning. The most inspiring instructors I ever witnessed avoided empty proclamations, and they aggressively sought the ideas of others. During their careers, “publish or perish” was replaced with “explore or expire.” By searching for information and knowledge for the purpose of discovery, not for the purpose of authoritative proclamation, one can develop the tools needed to elicit in a person a new and positive attitude, knowledge or skill. In short, to be a good teacher, you have to be a good learner. This principal is manifest in Orion Health projects around the world today.
When Orion Health began its work in New Zealand during the 1990s, its mission was to create hospital data-sharing that many in the industry did not think was possible. The Internet was nowhere near developed as it is today, and most companies did not possess the forethought required to engage proactively with emerging IT advances and evolving industry regulations. Rather than taking on the all-too-familiar bunker mentality of many organizations at that time, Orion Health embraced every opportunity to work in the literal and figurative foreign healthcare environments of countries such as Australia, the United States, Canada, Spain, Ireland, France, Saudi Arabia and others. While it required a great deal of flexibility, ingenuity and hard work, the insights and lessons learned through these very distinct sets of experience have Orion Health perfectly poised to be a leader within the international healthcare community for generations to come.
In the coming months, I will share living examples of how Orion Health executives and their clients work together to tackle global problems with regionalized solutions. You will be able to observe the efforts and decision making of several organizations at various stages of project implementation. These implementations are live and ongoing in America, Canada and Spain. By providing you with this unusual level of access, I hope to show how Orion Health’s strategies and technologies are not only effective in a variety of cultural and regulatory environments, but they should also serve as inspiration for other companies working to achieve the universal goal of increasing the health of a population one patient at a time.
The first updates of this living case study will contain transcripts of the interviews I conducted with, what I refer to as, project architects. These project leaders come from both Orion Health and the healthcare organizations they assist. They are responsible for the direction and stewardship of each implementation I plan to follow. As we move forward with the living case study, I will interview individuals who work and are touched by the implementations on a daily basis. These interactions should provide pragmatic lessons for outside healthcare organizations, regardless of where they reside in the world.
For my first interview, I spoke with Dr. Chris Jaeger, Chief Medical Information Officer and Vice President of Medical Informatics at Sutter Health. A not-for-profit health system headquartered in Sacramento, CA, Sutter Health has deployed the largest instance of Epic in the world. Dr. Jaeger’s work with Orion Health is placing Sutter Health at the forefront of American healthcare, but there is still a great deal of work needed in terms of establishing its health information exchange (HIE). I will interview Dr. Jaeger in the coming months to map Sutter Health’s progress. The points he raises in this initial interview will provide a broad picture of where its implementation currently stands.
As you read the transcript of his interview, keep in mind that at the heart of today’s most recent trends in healthcare is the need for focused efforts in gathering, analyzing and sharing information. Many organizations are short-sighted and only envision these processes occurring at the micro level with a single patient. These organizations are solely looking to create an ecosystem where a patient can have his or her entire health record in a single source, shared by a team of care providers and then used in follow-up or outreach efforts beyond the health organization. More to the point of this living case study is the notion that health organizations should strive to place themselves within a similar system of shared information on a macro level. Organizations need to investigate best practices within and outside their own systems. If they cannot perform these tasks on their own, companies such as Orion Health will prove to be, as Jaeger states, “invaluable” to healthcare organizations attempting to re-design their HIE systems now and in the future.
Jason Free: To begin, will you please describe how and when you joined Sutter Health?
Christopher Jaeger: I came to Sutter Health in the late 90s as a hospitalist working at one of its acute care facilities in San Francisco. I had been a member of an independent hospitalist group for just under 10 years. I was also going to business school during that period, and I got interested in healthcare IT. I wanted to move my career toward being more of an enabler of healthcare transformation than in the direction of being in the IT weeds, or what some would call the more geeky stuff.
I quickly found myself getting involved in Sutter Health’s EHR implementation project. Over time, I worked on broader health IT efforts, and I took on my current role as System CMIO about five and a half years ago. In that role, of course, I have been involved with the broad EHR implementation across our system, as well as other health IT efforts including the health IT-related parts of ICD-10, Meaningful Use, enterprise medical image management, dictation management – the list goes on and on. HIE is one of the more recent ones.
Free: For those who may not be familiar with Sutter Health, please describe the organization.
Jaeger: Sutter Health is a Northern California not-for-profit integrated healthcare network. Our 24 hospitals, 5,000 doctors affiliated with the Sutter Medical Network, five medical foundations and other healthcare services care for 3 million patients in more than 100 cities and towns. Today, we have the single largest instance of Epic in the world. We have rolled out Epic to each of our five medical foundations with over 2,000 physicians. We are live with Epic at 16 affiliated hospital campuses, with a plan to finish the rollout to the rest of the acute sites in 2015. We had to actually slow down our deployment schedule to allow for some technical infrastructure improvements, as well as evolution of the Epic platform to support the size of our instance. This is all important, because what it means is we have a completely integrated electronic health record across all our sites that are live on Epic.
A lot of organizations leverage HIE platforms to deal with internal integration issues. We don’t have that challenge for the most part. There are only small facets of our organization that aren’t live on Epic. One significant one is Sutter Care at Home, our home health and hospice organization. We will eventually migrate to Epic when it is able to support that function for us, but, to date, we have not felt it would be able to do so.
One of our current areas of focus is to leverage HIE to connect with the other care partners that help care for our patients. As a large, open integrated delivery network (IDN), we fully recognize that our patients get care from providers and entities outside of Sutter Health. Whether it be the Independent Practice Association (IPA) physicians (even in the aligned IPAs that are members of the Sutter Medical Network), skilled nursing facilities, nursing homes, dialysis centers, etc. It’s another list that goes on and on. In this broad healthcare landscape, we look to HIE to help us create that 360-degree view of a patient’s health information, as well as enable cure care teams the most effective communications possible.
Free: Orion Health has been a pivotal partner with these efforts, correct?
Jaeger: Oh, absolutely they have.
Free: When you were looking for a vendor partner, what were the criteria that you used, and how did Orion Health match the criteria?
Jaeger: We put together, as we do for most efforts of this sort, what we call a Value Management Team. This team consisted of stakeholders that will be impacted by the HIE, and they were the ones that participated in the request-for-proposal process we used to assess and select a vendor.
To help set up the requirements, I led an effort where I met with our system and regional Chief Medical Officers, CIO, VPs of Strategy, and Chief Medical Information Officers among other key stakeholders to define what their current, and potential future, connectivity needs would be. Those discussions were as much an educational experience for them as it was a fact-finding mission for me. We were sharing and seeking blueprints that we thought might meet our needs.
HIE was viewed by many as a simple results-delivery platform. During those internal conversations, we talked about the broader contexts of bilateral data exchange, secure communications, reconciliation of discrete data into an EHR and data aggregation for the purpose of population health analytics. The process opened eyes and helped people understand the full, very real, potential of a robust HIE platform.
Those new ways of looking at HIE led to the criteria we used to assess the different main vendors in the space. One of these critical criteria was experience with engaging with all the different EHR vendors out there that we knew we would have to exchange data with. We certainly did not have the internal expertise with respect to such engagement for the purposes of data exchange, and we wanted a forward-looking vision based on practical experience. We were looking for a company that wasn’t just on the cutting edge of what they were doing with information exchange, but that was providing stable channels for the business involved with healthcare transformation. We wanted to make sure we impacted areas such as care coordination, population management, so on and so forth.
Free: Did you consider Orion Health’s geographic footprint in healthcare during this selection process?
Jaeger: We did, but in the beginning, in all honesty, we did not have the right mindset.
We had some concerns about Orion Health not being U.S. based, and we also had some concerns about Orion Health’s existing customers at the time in the United States being largely public HIEs versus enterprise HIEs like what we were planning to deploy. However, we looked at their customers worldwide with open eyes and considered what we were trying to do as an organization. We then saw Orion Health’s global experience as being incredibly valuable. Our initial perceptions of the work Orion Health could perform with us was a bit off the mark.
Let me give you a bit more detail on this point. When we were looking at care coordination platforms, we frankly didn’t include Orion Health in the mix initially. That thought was due to the scope of effort including an analytics component that Orion Health doesn’t have as part of its core offering. As we assessed the different vendors, we realized our scope was probably too broad, so we broke it down into two facets. One was the analytics, and the other was the care coordination workflow support. We weren’t terribly impressed by any of the analytics providers that we saw relative to what we were using already. From a care coordination perspective, we identified a couple of best-of-breed vendors, but as we looked at them, we realized that Orion Health also has a care coordination module that can be layered upon the HIE, which made perfect sense from an integration perspective. When we included them in the assessment, and they presented to us, it was a great eye opener for many of our internal stakeholders. Many of our personnel working in care coordination were like, “Oh, yeah. That’s right. Other countries have been working on this for decades, and we are just getting started on it. We could leverage that experience and what Orion Health has been doing with those countries to help our efforts.”
Orion Health has travelled the world gathering vital information that would be nearly impossible for us to do on our own. Of course we have made site visits to outside organizations, such as Alberta Health, which was a tremendously important visit, but to have Orion Health’s international expertise at hand has been invaluable.
In hindsight, I am grateful we took the time to consider our situation and to make the connections with the work Orion Health performed in other countries.
Free: Many have the belief that America is not necessarily catching up to other countries in terms of healthcare because the industry is not really in a race. Our country has just now begun to move in the same areas that other countries’ healthcare organizations have been working in for the past few years.
Can you talk a little bit about that point? In general, do you see American healthcare organizations having to look abroad for solutions?
Jaeger: Yes, I do, and it will take companies like Orion Health to help healthcare organizations in America to make those transitions.
It’s widely known that America has the most expensive healthcare in the world, and we don’t have the best outcomes. We must fix that, and the evolving U.S. healthcare landscape is trying to get to this point. The whole accountable care organization (ACO) movement and new payment models are trying to help turn the course of this ship away from fee-for-volume to fee-for-quality and cost outcomes. That’s the way many other countries function and have been functioning for quite some time. They have conducted numerous care process transformations, and they continue to evolve their care processes to improve the quality and cost of care. We in America are currently trying to evolve our care model – I have no doubt we will implement processes in America that are current or past processes in other countries.
Free: Today, Orion Health is helping you create your blueprint, correct?
Jaeger: Yes, they are. We are setting up the core infrastructure for the HIE. As we complete that process, we are starting to design our blueprint for the broader deployment.
Free: Please walk me through the process.
Jaeger: In terms of our current thinking, it’s easiest to start with the clinicians. As we deploy the HIE from the clinician perspective, we want them to be able to have as comprehensive a view of the patient as possible – really a 360-degree view of what is going on with a patient.
As we look to the future, the goal is to partner with Orion Health, Epic and other vendors in the space on decision support. We want decision support that isn’t just based on data within the EHR, but within the HIE as well – decision support that can cross platforms so that providers who are using an EHR other than the Sutter EHR and seeing a patient who is also cared for at Sutter Health would see the same clinical decision support that providers see in the Sutter EHR regarding healthcare maintenance, disease risk or medical intervention for a condition. We also see such a platform as being a means of secure communication among providers to make transitions of care and the referral process much more efficient and effective than they are today.
From an organizational perspective, we hope to see a couple of things. The first capability is aggregating data to support performing analytics for population health reasons. This could be anything from hot spotting to using disease-specific registries to support care management of populations to improve outcomes.
From the individual patient and family perspective, we really see our efforts with Orion Health as putting the patient at the center of the care team. We talk about patient-centered care, as do many organizations, but, historically, and even today, most organizations are physician centric in how they provide care. We continue to strive to be more patient centric, empowering the patient and putting them at the center of the care team. To do that, they need to be able to have access to and to take their patient information with them wherever they receive care. For those patients, we see the HIE as bringing together their information from the separate entities where they receive care and putting it in a central place, so that as they move around their healthcare ecosystem, their medical neighborhood, if you will, they will have that information to empower themselves and empower their care providers to take better care of them.
Free: Can you describe some of the benefits Sutter Health is experiencing with the new process Orion Health is helping to create?
Jaeger: We already do a significant amount of health information exchange leveraging Epic’s Care Everywhere functionality. We exchange information with lots of EpicCare customers across the country – roughly 90,000 per year, and it is increasing significantly month by month. Through that, we already see a reduction in unnecessary laboratory tests and radiologic tests. This helps us deliver the right care at the right time to our patients, while also working to reduce the cost of care.
We also have an internal effort called the AIM program, the Advanced Illness Management program, where we actively engage patients with advanced chronic illnesses. Through visiting nurses, as well as telephonic case management, we work to help patients who have advanced illness to have compassionate, proactive care. The program has proven to help patients avoid unnecessary and costly emergency room visits and hospital stays. We help keep them in their homes, where they want to be, and empower them to cope with their illnesses and disease courses with dignity and caring support.
Free: It sounds like things are moving well at Sutter Health. I would like to check back with you in a couple of months to see how things are progressing with your efforts.
Jaeger: I would welcome that. By then, we should be able to provide your audience with more HIE lessons learned through our partnership with Orion Health.
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