and alternative payment model (APM) partnerships,
including new population health programs. Having
physicians well represented on the board and in contract approval is essential.
The second blank check is to share data around
any quality measure the ACO decides to report. At
Goshen, we use a software partner that downloads all
clinical data from the practices nightly.
3. Support Coordinated Care
Another best practice at Goshen is to provide care
coordination nurses. These registered nurses (RNs)
are ACO employees. They work with specific patients
in high-risk cohorts and targeted population health
programs on behalf of the physician practice to follow
up on specific patient findings from the ACO data and
close gaps in care.
RNs review each physician’s daily schedule and
automatically prep charts prior to patient check-in.
Patients falling into specific quality metrics are identified from the appropriate laboratory, imaging, or
questionnaires listed. For example, diabetic patients
must receive urine protein screenings every year. If data
demonstrate a gap in care, the ACO nurse can inform
the correct party to address testing while the patient is
in the office.
The care coordination program goal is to build a
bridge between the physician and the ACO. Physicians
pushed back initially. However, with combined data
from our Clinigence quality performance platform and
introduction of care coordinators, Goshen now shows
quality and performance improvement and achieves
shared savings in both government and commercial
contracts. Physicians are now asking for additional care
4. No Dump Trucks of Data
ACO data easily overwhelm physicians. This is especially true when their scores are low. Instead of giving
physicians dump trucks full of data, Goshen uses data
analytics technology to provide answers. Recommendations for specific patient care interventions to prevent
disease, improve health, and mitigate risk of adverse
events are shared with practices on a regular basis.
To ensure recommendations are correct, our ACO
conducts quarterly collaborative meetings with member
physicians to receive feedback, share data, and review
costs. These live, face-to-face quarterly collaboratives
include dinner and provide a safe environment to share
ideas. They are intended to:
■ ■ Explore gaps in care (e.g., emergency department
Five Ways to Engage Physicians in Pop Health
1. Work to create and maintain accurate data. Reliable data are the
foundation for physician trust and engagement.
2. Make mutually beneficial payer contracting decisions. Physicians
don’t want to be left out.
3. Provide care coordination support to physician practices,
especially for targeted population health programs and at-risk or
4. Communicate through weekly emails, regular scorecards, and
quarterly in-person collaborative meetings.
5. Implement strong data analytics technology to aggregate,
analyze, and report information back to physicians as quickly as
■ ■ Initiate dialogue with other specialists to discuss
ways to improve coordinate care
■ ■ Provide timely data tied to their daily schedule and
5. Deliver on Promise
report insights and share best practices
In addition to quarterly meetings, it is important
to give physicians frequent dashboard reports and
scorecards. Physicians are always interested in seeing
referral patterns and where their patients are going
for care. Weekly emails with one specific topic are
extremely effective in keeping physicians engaged and
Interoperability of all participating physicians’
electronic medical record (EMR) systems is essential
to deliver on the promise of population health management. Even if each physician practice is simply
connected through a health information exchange, consolidated views of activity by physician, by patient, and
by population are needed to monitor quality measures
Also, the ACO needs to know when and where
patients are being seen. For example, it is important to
track mammograms by organization, individual physician, and targeted patient populations to view referral
patterns and prevent leakage.
Finally, use analytics software to pull data from
EMRs and payer claims to combine quality and cost by
physician, calculating per-member-per-month costs.
The challenge is to obtain patient-specific data as
quickly as possible to affect care outcomes in real time,
not after the fact. Not all EMRs can accommodate this
type of fast reporting, and this is a key factor in choosing data partners.