Recently, Dr. Sean Rogers, medical director and compliance officer at Bend Memorial Clinic (BMC) shared BMC’s journey in leveraging health information technology for accountable care and population health management, and I found it to be an exceptional example of matching the right technology to the right care principles to improve health outcomes. Below are some of the key points of the presentation, including next steps and lessons learned.
The overarching theme of Dr. Rogers’ presentation was the integration of information technology and people, all in the service of delivering better patient care. To transition from our current healthcare environment to a true population health management style, we will now be responsible for guiding the health of an entire patient population – a hefty goal.
For Bend Memorial Clinic, the patient-centered medical home (PCMH) was the prime model to achieve this goal.
A Journey in PCMH
BMC, a physician-owned multispecialty group in Central Oregon, embarked on its PCMH journey in 2009. When the group realized this model would enable providers to deliver the kind of care it hoped for its patients, as well as help BMC be financially sustainable, it partnered with a local Medicare advantage plan and built a model around their joint PCMH principles.
For BMC, the key principle of PCMH has been the ability to deliver the “right care, to the right patient, at the right time, in the right location.” Dr. Rogers shared a fascinating story to demonstrate the power of the PCMH model for his organization: A 55 year-old man came to see Dr. Rogers and had been very healthy throughout his life, and hadn’t been to the doctor in over a decade. The staff members at BMC are encouraged to ask patients about preventative screenings and order tests if they are lacking, even before the patients see the doctor. A medical assistant inquired whether the man had undergone a colonoscopy and ordered the test when it was revealed he hadn’t. Through this preventative screening test, BMC discovered the man had Stage 3 colon cancer and renal cell carcinoma. A simple process change and a focus on team-based care saved this man’s life – twice.
How Technology Makes it Possible
Central to Dr. Rogers’ presentation was the idea that technology is profoundly important in the population health model. Below is the list of healthcare technology that BMC employs for population health – Dr. Rogers gave a great overview of why each is important in his presentation:
- Electronic health record
- Patient portal
- Electronic disease registry
- Patient outreach
- Quality metrics reporting
- Referral tracking
- Transition of care coordination
- PHI access for external providers
- Clinical decision support
- Health information exchange
- Predictive modeling
Specifically, BMC’s patient outreach solution from Phytel has driven meaningful outcomes for the organization. Over 1 year, 95% of BMC’s patients with a gap in care were successfully contacted, and 87% responded to confirm a visit. Dr. Rogers shared that he was initially skeptical about patients’ willingness to respond to calls, but the ability to efficiently and accurately reach out to patients who have gaps in care has been profoundly impactful for BMC.
Lessons Learned in Population Health Management
Dr. Rogers shared lessons that BMC has learned along the way of its population health journey. First, communication is incredibly important between all stakeholders. In addition, the importance of buy-in from senior management as well as the support of physician champions should not be underrated – these are key to driving change. Dr. Rogers also pressed the importance of adequate resource allocation, in regards to both money and people that can devote time to making your project a success; for example, whenever you are reporting quality metrics to physicians, you should always have dedicated resources validating the data to ensure it is sound. Lastly, don’t lose momentum once you get your project off the ground. Change is hard, so focus on proving the benefit of your efforts.
For BMC, the use of technology to improve communications, improve the identification of needed healthcare services, improve population health, and reduce cost are big goals, but ultimately achievable with the right tools and a focused commitment to succeed.
Learn More
To learn more about BMC’s journey, watch the full webinar here.
