Transitioning to Integrated Delivery: Measuring and Redesigning Care

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Jake NunnSuccessful health-care organizations will reengineer both their structure and processes as reimbursement shifts towards managing populations, and measurements are required to both support this transition and document its value, according to Jake Nunn. Radiology’s diagnostic role in the continuum of care provides a unique opportunity for participation in this transition, he says.

Nunn is director of imaging clinical integration with Aurora Health Care, Milwaukee, Wisconsin. He describes the 14-hospital health system as an “integrated delivery system focused on helping people live well.” Health system leadership has embraced the idea of needing to reform from within, regardless of what happens at the federal level, he says. “Our vision is to provide better health care than our patents can get anywhere else,” he notes. “Priorities are focused on a two- to three-year timeframe, with targets to measure our progress.”

One of Nunn’s roles in this transition is to integrate radiology practice across the health system with an eye toward eventually becoming an accountable care organization (ACO). “The existence of information in both the EMR and the PACS system provides an opportunity to use both sources to improve the quality of care inside of radiology, as well as to contribute to the tactics of becoming more accountable,” he says.

Appropriateness and Quality

One important area of measurement and data aggregation in radiology is dose, Nunn says. “This not only includes measuring and reporting patients’ dose or fluoroscopy times,” he adds, “but also providing information to affect decision-making prior to exposures, aggregating dose information to demonstrate improvements, and hardwiring solutions into the clinical process. Expectations are very high when you look at ACO and PQRS measures, and the only way to achieve the targets is through hardwiring processes.”

Appropriate utilization of imaging is an effective strategy in managing dose, he notes. “A comprehensive approach includes integrating appropriateness rankings into the electronic ordering process, making data available at the time of decision-making, and meta-analysis,” Nunn says. “Collecting information about clinicians’ decisions to go back retrospectively and work with them enables analysis of ordering patterns to improve utilization of the technology we have.”

Process redesign that integrates clinical data entry with the care process will be critical to making these changes part of Aurora’s culture, Nunn says: “Clinical documentation should be a byproduct of the care process, not an extra step. If it is onerous, it will not take hold in the long term.”

Other Areas of Transition

Redesigning clinician processes is only part of the process of transitioning to a more integrated delivery model, Nunn says. Aurora is also working to more closely align its disparate medical groups. Communication is critical in developing best practices that support becoming an accountable care organization, he says.

A practical example is establishing the interconnectivity required to support inclusive, prospective, multi-disciplinary conferences. “The efficiency with which radiology provides diagnostic information is important to the success of these discussions, while population management is supported by consistency of treatment options being provided,” Nunn says. “Without an efficient, well-designed conference system, it is very hard for the clinicians to achieve that goal.”

An example of interdisciplinary collaboration is Aurora’s Vascular Quality Steering Committee, chartered to improve vascular services system-wide. In one initiative, vascular clinicians from a range of specialties engaged in improving follow-up processes for patients. “This approach achieves the clinicians’ buy-in for process changes, which makes implementation more straightforward,” Nunn says. “Data on progress towards the established goal closes the loop.” Data-driven decision-making supports implementation of benchmarks and best practices, he adds.

He concludes by noting that radiology, contrary to much of what has been written, has a natural role to play in any organization’s evolution toward greater accountability. “Radiology data can document compliance with some of these federal measures, be they meaningful use, PQRS or ACO criteria,” Nunn points out.

“This extends beyond radiology specific measures into diagnostic information required for the overarching measures the organization