Center Releases HIE Toolkit

Joe Wivoda, Chief Information Officer

One of the groups that we provide technical support to are Rural HIT Networks. We identified early on that many of the networks were either in the process of selecting a health information exchange (HIE), participating in an HIE, or needed to understand HIE. HIE (as a noun) is a rapidly evolving technology that all health care providers will need to understand, particularly in the context of meaningful use. The Center looked for tools that would assist networks in being involved in an HIE but were unable to find many good tools. Therefore, we partnered with HIELix, a company that consults with HIEs across the country, to develop an HIE toolkit that would be appropriate for the grantees that we support.

This toolkit is exciting because it fills a void that has not been addressed when most folks talk about HIE (as a verb or noun!). For example, we had a number of questions about policies that were important to have in place when forming an HIE, so we put together a "Policy Matrix" that summarizes the necessary policies and provides links to samples that are available. In addition, there is a Privacy and Security Overview and Resource List that provides a "deep dive" into the issues of privacy and security when participating in an HIE.

Most of us feel comfortable that HIE can have a significant impact on patient care and communication to other providers, but we often need to justify the return on investment as well. The ROI Calculator uses referable studies to provide an estimate of the potential savings when an HIE is fully utilized. The feedback we have heard thus far has been very positive regarding this tool, and I encourage everyone who is thinking about participating in an HIE to go through this spreadsheet. If you are implementing an HIE, we are putting together a pricing model as well, but it is not ready for "prime time".  Let us know if you have a need for this, or some ideas!

Other tools that are part of the toolkit are the HIE Direct Guide, which is designed to assist hospitals and providers in understanding and implementing Direct, and the First Considerations document, which discusses first steps in forming or joining an HIE.  These are great resources for anyone who needs to understand Direct or is joining an HIE. They are written with as little "techno speak" as possible!

Take a look at these resources, give us feedback, ask us questions, and help us improve them! We are excited about these tools and hope they will help hospitals, clinics, long-term care, homecare, and other providers. With meaningful use Stage 2 starting in just a few weeks, HIE participation will increase and we need to move quickly. Besides Stage 2, better communication between providers is so important in patient safety and quality of care that we need to use HIE (noun) to improve our processes for HIE (verb).

Oh, and sorry for the grammar confusion!

Rural Quality Programs using the Baldrige Performance Excellence Framework

Margo Kulseth and Kap Wilkes

In our work with the Rural Quality grantees over the past year, Kap Wilkes and I set out to discover how key sustainability success factors are integrated into such programs. We hypothesized that these success factors would be closely aligned with the Baldrige Performance Excellence Framework, so that became our starting point in designing our approach. We conducted an online assessment and several key informant discussions with grantees from the current and previous years’ grant cycle. We also facilitated a workshop for grantees to discuss key activities specific to sustaining a quality program. In talking with their peers, grantees identified lessons learned, including challenges of implementation and successful results.

Not surprisingly, we found the grantees are already doing many of the components of the Baldrige Performance Excellence Framework, but we did not see much evidence of a systems approach to the grantees’ efforts. Following are brief descriptions of the key sustainability success factors and findings from our recent work with the rural quality grantees.

Leadership: enhancing leadership awareness, alignment and capabilities

This is a time of dramatic change in health care, and it appears that the Rural Quality Program and other health care leaders are paying attention to the changes and looking for ways to adjust to the developing health care landscape. This is a critical part of leadership awareness and one of the key sustainability success factors.

What we heard from the grantees is that their quality program goals are very much in line with health care reform. For example, the disease registries they created and their focus on chronic disease management meet all three criteria of the triple aim: better health, better care, lower cost.

Strategic Planning: planning and aligning vision, strategy, and initiatives

Grantees were using strategic planning methods to align their vision and strategies with their initiatives and action plans. They were also regularly communicating about this strategy with leadership, striving for alignment with the mission of the overarching organization.

Patients, Partners, and Communities: engaging patients, partners, and community for improved population health

This criterion guides in the examination of how an organization engages customers to attain long-term success in the marketplace. This includes how to listen to the “voice of the customer,” build customer relationships, and use customer information to identify opportunities for improving their communities’ wellness.

Many grantees said they keep in touch with their patients, partners, and communities by using mailings, phone calls, newsletters, websites, social media, patient portals, meetings, health fairs, free educational events, and especially face-to-face communication as much as possible. They were effectively partnering with many other kinds of organizations and working together toward the health of their communities.

Measurement, Feedback, and Knowledge Management: evaluating progress, managing knowledge, and utilizing tools and resources

Although technology advances quickly and can be challenging to learn and use, the implementation of electronic health records has made it much easier to track and measure all kinds of data. This, in turn, has allowed rural quality grantees to use the feedback to spot areas that need improvement. Technologies, such as webinars and intranets have made it easier to share information with each other, learn new things, and help organizations manage their knowledge.

Workforce and Culture: developing workforce capacity and a quality-focused, change-ready culture

When asked to describe the culture of their organizations, grantees responded with some long pauses and some laughs. We noticed that their intentional focus on patient safety and quality was obvious. Also, many described an ever-changing workplace. Some talked about those that were resistant to change and how they have fallen by the wayside. Being change-ready is crucial in today’s health care environment. Part of success is tied to responding quickly and being prepared for anything. Some grantees also shared that the new methods of measuring data have created a healthy competition among their care providers.

Operations and Processes: continuously improving processes, services, and products

Several of the Quality Improvement methodologies mentioned by this group of Quality grantees included Plan/Do/Study/Act, Chronic Care Model, and Lean. Using technology is also a very important part of improving operations and processes, including electronic health records and patient portals. Continuously improving processes is a mindset that supports sustainability.

Impact and Outcomes: calculating and communicating value and impact

There are many benchmarks to use, including national standards like Healthy People 2020, as well as regional, state, local, and internal standards. The important thing is to use benchmarks to show progress is being made and then communicate that success to as many audiences as possible. Grantees said demonstrating the value of their programs to funders was helping their programs to continue and grow.

In talking with the Rural Quality grantees, it is obvious to us how passionate they are about the important work they are doing, and we are excited about the successes within each of the components. However, we do not see much evidence most of them are thinking in terms of a systems approach. Our hope is that as the grantees continue to implement aspects of each Baldrige component, they begin to see the integrated nature of the activities and consider them as a system. Using a “systems thinking” approach such as the Baldrige Performance Excellence Framework, we believe, is the key to sustainability of rural quality programs.

 

Employment Forecast for Minnesota's NP and PA Workforce Continues to Soar

Angie LaFlamme, Program Coordinator II

Minnesota is suffering from a primary health care workforce shortage and the road to improved population health begins with increased access to care. A large portion of the primary care workforce is nearing retirement while fewer medical students are choosing primary care as their specialty. These shortages are particularly significant in the rural parts of Minnesota. Clearly there are benefits of Nurse Practitioners (NPs) and Physician Assistants (PAs) to health care organizations, and the Obama administration has championed NPs and PAs as an important part of the answer to our nations' health care problems.

Growth in the number of PAs has grown substantially in the past several years. In March 2012, Minnesota had over 1,700 licensed PAs, over three times the number from 10 years ago. According to Health Guide USA, PA opportunities are expected to increase 30% from 2010-2020 due to increased need. This should be particularly true for PAs working in rural and medically underserved areas, as well as those working in primary care. With more physicians entering non-primary care areas of medicine, there will be a growing need for primary health care providers, including PAs. Additionally, general population growth and an increase in the number of insured citizens, due to health care reform, will further spur opportunities for PAs as more people seek health care.

Physician Assistants are master's degree prepared health care professions licensed to practice medicine under physician supervision. They are trained to examine patients, diagnose injuries and illness and provide treatment. Until recently, there was only one established PA program in Minnesota, belonging to Augsburg College in Minneapolis. In the summer of 2012, St. Catherine University in St. Paul opened their new PA program. These two programs graduate approximately 55 students each year. Bethel College is scheduled to accept their first PA students in the fall of 2013 and the PA program at The College of St. Scholastica is tentatively scheduled to open in 2015. There is also a strong connection with Mayo Clinic Health System, located in southern MN, and the University of Wisconsin-LaCrosse Gunderson Lutheran PA program.

Minnesota currently reports nearly 3,100 licensed Nurse Practitioners. According to the Bureau of Labor Statistics Occupational Outlook Handbook, 2012-2013 Edition, NPs will enjoy a forecast of increasing job opportunity. All four categories of advanced practice nurses (Nurse Practitioners, Nurse Midwives, Clinical Nurse Specialists and Nurse Anesthetists), as well as Registered Nurses, will be in high demand, particularly in underserved populations like rural and inner-city communities.

Nurse Practitioners programs are now offering a Doctorate degree (DNP). Minnesota currently has 7 NP programs throughout the state: St. Catherine University, The College of St. Scholastica, Metropolitan State University, Minnesota State University Mankato, University of Minnesota, Walden University and Winona State University. These programs graduate approximately 135 students annually.

Nurse Practitioners currently serve patients in a wide variety of settings under varying degrees of physician supervision. They can prescribe medication, often function as primary caregivers in many locations and can choose to specialize in whatever aspects of health care interest them most. The most common specialty for NPs is family medicine, followed by adult, women's health, gerontology and pediatrics.

Primary care providers are often a patient's first point of contact in the health care system and increasing the role of NPs in providing primary care services has the potential to help alleviate the primary care workforce shortage. One option for states is to re-examine the scope of practice laws governing NPs. The American Academy of Nurse Practitioners (AANP) is focusing on: improving Medicare regulations to include NPs' patients as beneficiaries in accountable care organizations (ACOs); the ability of NPs to order/certify home health care services for Medicare patients; Title VIII funding for NP education programs; and traineeships and, funding for nurse-managed centers.

While an increase in education capacity and recruitment of providers is part of the workforce shortage solution, retention is equally as important. There are many elements involved as part of a successful retention plan such as orientation, practice feedback and satisfaction surveys, recognition activities and mentor programs to name a few. Some retention factors that are most important health care providers include: availability to relieve coverage; availability of specialists; income potential; help with retiring education loan; compatibility with others in health care, and quality housing and schools.

The National Rural Health Resource Center and the National Rural Recruitment and Retention Network, under contracts from the Indiana State Department of Health, Minnesota Department of Health Office of Rural Health and Primary Care, and the Wisconsin Department of Health Services Division of Public Health, has created the Midwest Retention Toolkit.

Another great retention tool is loan repayment. Minnesota offers three different federal and state programs to NPs and PAs. The Minnesota Rural Midlevel Practitioner Loan Forgiveness Program is offered to midlevel practitioner students, which includes Nurse Practitioners, Certified Nurse Midwives, Nurse Anesthetists, Advanced Clinical Nurse Specialists and Physician Assistants. Through this program, the above providers can receive $6,750 annually for a minimum of three years and a maximum for four years of service in rural Minnesota. The Federal National Health Service Corp Loan Repayment Program offers full-time providers $30,000 annually for a minimum of two years and a maximum of four years of service in a health professional shortage area (HPSA). The Minnesota State Loan Repayment Program provides recipients with $20,000 annually by completing a two-year service obligation in a nonprofit private or public site that is located in a federally designated HPSA.

With more national focus on prevention rather than just treatment, approximately 35 million newly insured individuals, many practicing physicians expected to retire and an aging population, expanded use of NPs and PAs could be critical to the delivery of primary care and the increasing health care demands in this country.

Rural Quality Programs Living the Triple Aim

Kap Wilkes and Margo Kulseth

"Wow," was my thought after listening to and talking with the Rural Quality grantees at their annual meeting in May. They are doing great work for improving health in their communities. They are living the Triple Aim and having an impact on the health of the people in their communities. I heard this not only from the select panel members but from around the room in the discussions, conversations, and discourse that took place through the entire gathering; improving care, making an impact on better health, and reducing costs leads to a healthier community!  

The discussion and discourse was particularly robust during the last morning when Margo and I suggested and provided a common vocabulary of key sustainability success factors. We didn't stop there, we also provided an opportunity for the rural quality grantees to practice using these words and ideas in a workshop format. In that workshop rural quality grantees talked about key activities that are specific to sustaining a program. This was followed by a deeper discourse on lessons learned. These lessons learned define the path that any program leader can leverage to sustain impact on the health of their communities.

The term “sustainability” is used quite a bit and can mean different things to different people, for example, financial sustainability, operational sustainability, or outcome sustainability. The definition can shift depending on the person, the project, or the circumstance. However, the basic assumption we presented to the rural quality grantees is that all of these perspectives are the right answer if we define sustainability as "continuing to have impact past the life of the grant.” 

Throughout the rural quality grantee meeting and during the beginning of our workshop, Margo and I heard about a lot of different activities within the defined Key Sustainability Success Factors  that the grantees are accomplishing and are engaged in implementing, including: planning, measuring, collaborating, communicating, documenting, and analyzing. The challenge for Margo and I is not only to identify activities or discover lessons learned; the real challenge for us is to illustrate and convince the leaders of these quality programs that the ultimate success factor is to see these activities through the lens of a system. We are ultimately suggesting it is management of the key success factors, components of a performance framework that is key to sustainability.

We recognize and acknowledge that doing this work of improving health and living the Triple Aim is complicated, but we are convinced that a Performance Framework utilized within a systems approach to manage this complexity is the primary key to sustainability. We also believe this sustained effort on improving the health of communities will lead to a tremendous amount of change and transformation in health care. The National Rural Health Resource Center is using and encouraging other health care organizations to use the Baldrige Performance Excellence Framework as a management tool to focus on quality and performance. The most significant benefit of using a framework within a systems approach is that it provides structure and guidance. This is true of the Baldrige Performance Excellence Framework. It can be trusted and relied on because it has been used successfully for amazing gains in performance and sustaining complex organizations over more than 25years.

The Baldrige Performance Excellence Framework is a management tool to focus on quality and performance. The National Institute of Standards and Technology, Baldrige Performance Excellence Program describes the history and objective of the Baldrige Program in a 2011 report,  Baldrige 20/20, An Executive’s Guide to the Criteria for Performance Excellence, forward by Rosebeth Moss Kanter. The Baldrige Program “was developed in response to a crisis in U.S. competitiveness several decades ago.”“American manufacturing was losing ground to Japanese companies which had adopted quality improvement systems taught to them, ironically, by an American, W. Edwards Deming, as part of the rebuilding effort after World War II.”  Deming is credited for the Plan Do Study Act cycle. “By the mid-1980s, Japan was an economic powerhouse, and sluggish U.S. companies were under pressure to seek performance excellence and innovation.” “The rise of Japanese industry, from automotive manufacturing to electronics, cannot be written off as due to low-cost labor; it is clearly seen as emanating from outstanding management systems.”

In 1987, the U.S. government created the Baldrige Award based on seven specific components and associated performance excellence criteria, “to encourage American companies to examine their practices, benchmark against the best companies, and make necessary changes to become leaner, faster, and more customer-oriented, and responsiveness to multiple stakeholders; all in pursuit of high performance.” Although it started out as a business framework, criteria for health care organizations were added in 2002. The Baldrige criteria are a much used and respected management tool across multiple sectors including manufacturing, business, healthcare and education.

The results from healthcare organizations that have implemented the Baldrige criteria illustrate the impact of utilizing a performance framework within a systems approach. Quality has improved at one hospital with a 57% reduction in mortality resulting from pneumonia over three years. For another hospital there was a 24% increase in net operating margin over two years. Regarding patient satisfaction, in the year before one health care organization as a whole received the Baldrige Award, they were ranked as “the nation’s no. 1 hospital for overall patient satisfaction.”  Another hospital experienced nearly a 50% decrease of registered nurse voluntary turnover rate over two years.

While no management system can predict exactly what challenges will be faced in the future, using the Baldrige criteria as a framework will mean that you are better prepared to meet unexpected challenges, have a focus on results, have systematic processes in place that are effective and regularly evaluated for improvement, have a system that is responsive to customer and stakeholder need, and is integrated into operational areas.  Margo and I can attest that the Rural Quality Programs are indeed living the Triple Aim. They are making a difference and having an impact.  We are suggesting that to sustain those efforts the next step is to manage their work using a performance framework; a systems approach that will sustain the triple aim; improving quality of care, increasing wellness in our communities, and reducing the cost of health care.

The best deals in cars and care may be found at the end of the month.

I have been a physician for almost 20 years, and my income has been going down- a lot.  With the rising cost of insurance premiums this might seem counter intuitive to many Americans.  However, there is an explanation, albeit a perverse one, that helps explain this disconnect.

There is no cost of care.

Unlike most markets, there is no fixed price for care.  What you pay depends on whether you have insurance, the terms of your insurance and  the rate that has been negotiated on your behalf. Different insurers negotiate different rates for the same service.  For instance, a CT scan or blood work may be paid at a factor that is 2 or 3 times more than another insurer.  In part this has to do with other services the insurer needs.   For example, access to specialty coverage may be offered by a care delivery network to an insurance company in exchange for higher reimbursement on other services.

Rather than bill everyone at the lowest negotiated rate, not surprisingly hospitals tend to bill at the highest one.  Everyone gets caught in the same net. The hospital don't want to miss out on the highest possible reimbursement for a particular procedure.  Unfortunately, the person least able to pay, the uninsured patient, gets billed for the largest amount as well.


Imagine if Walmart's everyday low price depended on your ability to pay?

   My salary is made up of a mix of payers- payment for the same CT scan can vary widely.  Lately, my practice has seen increasing volumes, some decrease in insurance reimbursement/case, and a large increase in the ability (or willingness) to pay for services by the uninsured.  Based on the mix (insured and uninsured) we now collect something like 28 cents for every dollar billed.  Imagine if Walmart collected 28 cents on the every dollar?  I am betting prices would go up.  This  isn't good for me, and it isn't good for the consumer.  

Given the large uninsured population of my downtown hospital, some analysts predict Obamacare may actually improve this 28% reimbursement.  This presumes reimbursement for each case will decline, but  the portion of charity cases will decline more- everyone will be insured.  However, with the same size pie, this will have short term issues for other segments of the market, and is not sustainable. 

Fair care at a fair price- the end of the month, cash may be king.

Like many things in American healthcare, the billing system is byzantine, kluged together with no real thought or roadmap.  Until we deal with this fundamental disorganization, I expect the general mistrust between patients, physicians and insurers to rise.  Insurance premiums are currently viewed as a surrogate for physician salaries.  This is simply not true.   Medical costs have gone to such extremes that the number of Americans with no insurance is rapidly expanding and now make up an increasing pool of reimbursement.  Ultimately, we have to pay for care if we want to have services moving forward.  I would far prefer to get paid a fair price by all patients.   When you are sick and most in need, adding financial pressures fundamentally seems wrong.  

Ideally each bill would be somehow be "patient centric."   However, today's financial tools do not allow this level of service.  What I can tell you is that hospitals and providers have a discounted price, one that is much closer to their cost of business.  Asking for a negotiated rate, particularly for the uninsured/self pay, will likely to be met with interest.  I am not sure what this rate is but it is something less than 100% and more than 28%.  And sadly, like car dealers, from what I have been told, the best deals may be found at the end of the month.

RAP Lesson Learned #3: The Power of Team

Rhonda Barcus, Program Specialist

Lately, I have shared a little about two of the lessons I learned from conducting RAP interviews with hospital leaders. We conduct these interviews in order to gather outcome data from hospitals who have participated in an onsite consultation through Rural Hospital Performance Improvement (RHPI) Project. The first lesson was about the “power of a conversation” and the second concerned the power of “meeting people where they are.” The third lesson involves the rich abundance created from Team.

When I contact an administrator to schedule time to talk about the RHPI project, I encourage other leadership members to join the conversation as well. The really wise administrator usually makes sure the leadership team is included in the conversaton! The richness of the RAP interview increases exponentially when the team is present. This isn’t because there are just more people to talk; it’s because each person brings a unique view and experience which more clearly reflects the many facets of the project. One person might be more data-minded while another can speak more easily of the impact of a project on the patient and another might discuss the impact of a project on the employee. The really smart administrator knows there isn’t just one “right” point of view but instead, many pieces reflecting different aspects that give a more complete picture.

In his book, The 7 Habits of Highly Effective People, Stephen Covey describes the importance in Habit 6 for the need to “synergize.” This is defined as “creative cooperation.” I once worked with a manager who was a master at this concept. While many managers tend to hire employees that are similar in style and personality to his or her own, this leader would purposelyseek out new employees who brought a different view. He knew that strength was found in a team, and a diverse one at that, and that to try to maintain a narrow way of thinking, where everyone agreed on everything, would only weaken the ability of the team to build this “creative cooperation.” The key wasn’t to develop a team with only one viewpoint but to choose team members with different views AND who also had the ability to cooperate.

This power of team is one of the really important lessons learned from RAP. The first time I called an administrator at the time of our meeting and he had included a number of his leadership team, I was actually taken aback. In the two years of interviews though, I’ve discovered it’s almost predictive. The interview that includes the whole team is usually the one that results in some of the richest outcomes data. It is as if the culture is “we are all in this together” from project beginning (planning) to end (outcomes) and every single person has an important piece to contribute.

RAP Lesson Learned #2: The Power of Meeting People Where They Are

Rhonda Barcus, Program Specialist

Last time, I shared a little about the first lesson I learned from RAP(Recommendation Adoption Process), the process we use to gather outcome data from hospitals who have participated in an onsite project through Rural Hospital Performance Improvement (RHPI) Project. That first lesson was about the power and impact of just having a conversation with someone. The second lesson concerns the power of “meeting people where they are.”

 

RAP involves asking lots of questions about how the hospital implemented the consultant’s recommendations and how that affected measurable outcomes. This is a conversation which could easily put someone “on guard”, feeling like they have to justify their actions, or sometimes, inaction. When we created the RAPprocess, we based it loosely on an organizational development model called Appreciative Inquiry (AI). AI focuses on discovering what is going well and the strengths and assets and seeks to create more of what already “is.” This approach is very unlike the medical model or problem solving model which focuses on the deficits, illness, or problems. 

The first question in the RAP process is “Tell me what is going well.” As the administrator (or sometimes entire leadership team) begins talking about their successes, my next question is “and what else?” We continue with this line of questioning until they can no longer name another success. The power of this approach is that it often leads to the interviewees saying, “Wow, I didn’t realize we had accomplished so much!” 

The next part of the conversation is geared towards next steps or discovering what hasn’t gone well. Instead of asking about the problems, the focus is on what the hospital would be doing to create the best possible outcomes from this project. The question then might be, “If you could imagine the best possible outcomes for this project, what would you all be doing more of or differently?” This very naturally leads into a discussion about recommendations not implemented or setbacks to the project. Done in this way, the conversation is not defensive or negative because in the spirit of AI, it focuses on “what could be.” It is a subtle, but very effective way to get at the barriers or sometimes resistance but does so in a way that is motivating to moving forward.

The other critical piece of RAP that reinforces “meeting people where they are” is the way the stage is set from the beginning of the conversation. We have discovered that most projects take one to two years to implement. I always begin a conversation by letting the hospital know that. There is often a sigh of relief heard through the phone followed by, “Thank goodness, we were worried you would think we hadn’t done enough.” It is amazing the incredible amount of work most hospitals have already done on a project but they expect to be told that they should be finished in nine months. Thorough and thoughtful implementation takes time but is more likely to lead to a sustainable project with lasting results.

Next time, RAP Lesson Learned #3: The Power of Team.