Bridget M. Kuehn

On the day after Congress repealed the Medicare Sustainable Growth Rate (SGR), Farzad Mostashari, a former Brookings Institution fellow and U.S. National Coordinator of Health Information Technology, was prepared to wager that the winners in this new era of healthcare payments would be primary-care physicians and practices.

"Who's going to win in this new world?" he asked during one of his sessions at the 

Healthcare Information Management and Systems Society (HIMSS) Annual Conference

. "I would say it's the people who have the least to lose and most to gain."

Many large health systems are reliant on the fee-for-service model for survival and have a disincentive to prevent hospitalizations because they make money when patients' conditions worsen, explained Mostashari, who created and now runs start-up Aledade to help practices form accountable care organizations (ACOs). But primary-care physicians have long taken a more holistic view of their patients and are in a good position to take charge of keeping their patients healthy through physician-led ACOs.

This path is not an easy one, however. He cautioned that so far, 75 percent of the physician-led ACOs aren't yet profitable. But by 2018 the changes in reimbursement associated with the SGR repeal, which offers physicians a 0.05 percent annual fee increase, will make ACOs and other Medicare-driven alternative models more attractive, Mostashari said.

"We have to nail [ACOs] in the next two- to two-and-a-half years," he said.

Fortunately, the secrets to physician-led ACO success have been well publicized. Mostashari and his former Brookings Institution colleagues published 

a free toolkit describing the keys to ACO success

. During his talk at HIMSS15, Mostashari summarized this information.

The first thing successful ACOs must do is harness their data to identify the highest-risk patients so they can prevent them from being hospitalized or having other expensive negative outcomes. But it is not as easy as just finding the most expensive patients, he said.

"Often we can't do anything about the highest-cost patients," he explained. "It's too late; the springs have come off. We've failed them."

Instead, he said ACOs must to use data to identify the patients helped before they become high-cost patients. For example, patients who have a high fall risk, who are taking several medications, who have congestive heart failure, or who are living in a dangerous home situation. Mostashari acknowledged, however, that it may be difficult to extract relevant data from current EHRs leaving some practices to rely on a separate population health system.

He noted it is important for ACOs to also tap their physicians' clinical experience and intuition because they may know about factors that mitigate or exacerbate the risks outlined in the data. For example, if a patient has regular family visits and support with their medical care.

Physicians also need to be alerted when their patients enter a hospital and be prepared to respond and share data with hospital clinicians.

"You are not doing population health if you don't know when your patient is in the hospital," he said. "Good luck managing health costs if you don't know that."

A primary-care physician sending an emergency department physician relevant patient data or discussing the case may well be a deciding factor in whether the patient is admitted, Mostashari explained.

Additionally, physicians must build a network of other physicians and facilities so they can ensure the quality and continuity of their patients care. Finally, Mostashari emphasized the importance of engaging patients and their families in care.

"Do what is right for the patient and the quality measures will follow," he said.

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Using available data to identify potential high-risk patients before they become high-cost patients can reap rewards for accountable care organizations.

Smart Data Use a Key to Physician-Led ACO Success

Before a patient even walks in the door, he's already generated a first impression of his physician and practice based on what he's found online.

"Our patients have formed an impression before they've met us [in person],"said Nick Van Terheyden, the chief medical informatics officer for Nuance Communications during the 

To make sure that first impression is a good one it helps for physicians and practices to have an active presence on social media platforms such as Twitter, Facebook, and LinkedIn, he said.

cited data from a recent survey by Nuance

 that found about 40 percent of patients check online sources in advance of a visit with their physicians. Data from the 

 suggest that one of the first places patients stop is Google or other search engines. Among the first results for such searches are usually social media accounts.

"This is happening, and if you aren't accessing it you are missing an opportunity to interact," Terheyden cautioned.

For example, he noted that one of the things that patients may find when they search for a physician's name are patient reviews on physician review sites. These sites offer the opportunity for physicians to post a profile picture and may offer an opportunity to respond to reviews. He suggested that physicians be aware of the reviews they are receiving online and to post photos and other information on such sites to create a positive impression.

Many businesses and organizations, including Dell, actively monitor social media for mentions and complaints about their company and products. This monitoring gives them an opportunity to quickly respond and provide a better impression of their service, Terheyden explained.

Hospitals and practices are also getting in on the act with their own social media patient outreach. Terheyden highlighted several ways healthcare organizations can use social media to enhance patient engagement, including community engagement, real-time patient education, outreach to referring physicians, customer service, and crisis communications.

It can be intimidating for physicians and practices to dip a toe in social media, Terheyden acknowledged. But he suggested they start slow by setting up accounts and following what other practices and health organizations are doing on social media. He suggested that physicians follow colleagues and others they know in the industry. One way to follow conversations on Twitter is by following hashtags (#). For example, typing in #HIMSS15 allows Twitter users to view tweets relevant to the HIMSS meeting.

Practices should establish policies for social media use and train staff to avoid inappropriate posts or posts that could violate patient privacy, he said. For example, the Mayo Clinic 

Ultimately, Terheyden said that interacting with patients is really the key to successful social media use and it can be a powerful tool for patient engagement.

"It's about collaborating, interacting, engaging, and learning from our patients," he said.

Practices can interact with patients in many ways using social media: from community engagement to patient education to crisis communications.

Social Media Leads the Way in Patient Engagement

Too many organizations focus on the initial implementation of an EHR and too few spend enough time on sustaining successful adoption and use of the system over the long term.

That's, according to Heather Haugen, senior vice president of research at the Breakaway Group during a session at the 2015 

"Sometimes we get caught up in the wedding and forget the marriage," said Haugen. She explained that organizations will spend years preparing for the "go-live event," but afterwards don't put in the continued effort needed for success.

As a result, many organizations implement EHR systems but never get the value they were hoping for. Research by Haugen and her Breakaway colleagues that included interviews with more than 3,000 clinicians and executives found four keys to successful adoption of an EHR: engaged leadership, efficient and effective training, data sharing, and sustained efforts to support adoption.


First and foremost, she said it is necessary for practice leadership to be focused and actively engaged in the process of adopting an EHR. Too often, she said competing priorities cause executives not to be engaged.

"If an EHR adoption is not in your top three priorities [as a practice] it is very hard to get it done," she said. "As leaders, we should ask: What are the things we are going to stop doing to do other things well?"


The next key is how quickly the organization is able to get its staff proficient in using the new system to provide care. Haugen said it is important for training to be provided in "bite-sized" time periods and as close to implementation as possible.

"Time may be the most precious asset to any clinician," she said.

Training should ideally focus on realistic simulations that help walk clinicians and staff through the specific tasks they will be using the EHR for, she said. It should not spend a lot of time detailing the various features of the EHR.

"The clinicians don't care [about functions], they want to provide care," she said.

Organizations should also test staff to assess their proficiency at using the application, and leaders should observe the use of the EHR in action to identify what's not working well in order to address corrective measures.


Another key is early and frequent use and sharing of data from the system. Haugen explained that the first thing that practices and hospitals should measure is how proficiently staff is using the EHR. Otherwise, any data may be inaccurate. Next, they should focus on a few data areas and share that information with their clinicians to help them improve care.

She said that physicians are naturally analytical, so having data will inspire them to look for ways to improve care and will help them see value in using the EHR efficiently.


The final key is ongoing leadership and continued efforts to maximize adoption of the EHR over its lifespan. Haugen said many organizations assume that they are proficient years after an application has been installed. However, proficiency can fall off over time if new employees aren't trained well and staff share work flow workarounds. Additionally, someone needs to be in charge of preparing staff for upgrades and training incoming staff.

"You have to stay engaged for the life of the application," she said.

Research indicates there are four keys to successful EHR adoption. Here's how to implement them at your medical practice.

Ongoing Engagement Critical To EHR Success

Leaders at a 100-physician practice in Kansas and a neighboring hospital system shared the same concern when they launched separate patient portal systems: What if patients chose to use one portal over the other? Patient choice could have a huge impact on both systems' attestation to CMS' meaningful use program.

That was the dilemma described by Laura McCrary, executive director of the Kansas Health Information Network (KHIN), a non-profit member health exchange, and a speaker at this year's 

But using the statewide patient portal offered by KHIN could have solved both organizations' problems, she said.

"If you share a portal, every time a patient looks at info in the portal it counts for [both the hospital and practice]" McCrary said. "It allows our providers to work together."

Statewide portals such as KHIN's are one solution to the emerging problem of patients accumulating multiple portal logins and passwords from multiple providers as more organizations embrace these electronic patient engagement solutions. They offer other advantages as well, including allowing organizations that couldn’t afford a portal of their own to use one and giving patients an easy to use and comprehensive portal for their health information.  But there are also technical and other challenges to creating a statewide portal system, explained McCrary.

So far, 38 organizations of KHIN's 1,000 member organizations have opted to use the statewide MyHealtheRecords portal. The portal is one of two available in the state. Kansas required both of its private health information exchanges (HIEs) to offer a statewide portal.

Convenience for patients is a big benefit of a statewide portal like KHIN's system. Patients get all the information included in the summary of each patient encounter in one location. They can upload other information, and print out a pocket-sized summary of their medical information for emergency service providers, said Michelle McGuire, the senior project manager for KHIN. It also includes linked and searchable patient education materials from Healthwise. Individuals who are managing care for a child or older parent can also tie their portal accounts together.


But there were initially some challenges for providers who had to manually upload the patient summary and securely e-mail it to the patient, McCrary said. That step has since been automated. Physicians currently have to authenticate patients onsite in order for them to set up their account in the portal, but eventually patients will be able to self authenticate.

There were also technical challenges KHIN didn't anticipate. Currently, the patient portals query the HIE every six hours for new information. But now that more than 10,000 patients are using the system, this is becoming unsustainable, McCrary said. So KHIN is working on a way for the HIE to automatically push new data to the portals.

Another challenge was managing the links between parent and child portal. The system can automatically unlink a child's portal from their parents when they turn 18. But the state of Kansas allows children to have medical privacy from their parents as soon as they become sexually active, McCrary explained. So the system had to create a way for physicians to mark some information as only viewable by the child.

Going forward, several upgrades are planned for the patient portals, including adding more patient information.

"We are always looking for ways to expand and make it better," said McGuire.

For more information on how KHIN assists physicians, visit 

"Health Information Exchanges: A Progress Report."

In Kansas, one of two statewide patient portal systems has overcome a series of challenges to improve communication between physician and patients.