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Population health management * Coordinating care for veterans * New big data hub
abraham-tomoloCoordinating care for veterans with dementia big-dataBig data hub linida-mccauleyIn brief
November 16, 2015

Making strides in population health


As the march continues to change the way health care is provided and paid for in this country, Emory Healthcare is making measurable strides in the art of population health management, which entails cutting health care costs and improving outcomes on a large scale.

Richard Gitomer, Cathi Durham  

"It's clear that the fee-for-service world is going away," says Richard Gitomer, president and chief quality officer of the Emory Healthcare Network (EHN). In that world, you wait for patients to get sick and then react. In the new world, you provide proactive care to help patients stay as healthy as possible. "You ensure they receive the care the provider intends, and you reduce the need for unintended care, such as ER visits and hospital admissions."

What's also clear, he says, is that fee-for-service payments are going away. By 2019, 25% of payments from Medicare (the world's largest health insurer) will need to be in an alternate payment model for the provider to receive an incentive bonus and avoid a penalty. By 2023, the number climbs to 75%.

Need for high volume: To keep patients healthy on a population scale, you need a broad network of providers and patients, says Gitomer. Thus, a key element in Emory's population health strategy is the EHN itself, which has some 200 sites and 2,000 physicians. EHN encompasses all of Emory Healthcare's components, including faculty practices in the Emory Clinic, Emory-owned practices in Emory Specialty Associates, and a growing number (currently 460) of non-Emory-employed private practitioners, both generalists and specialists. "We engage these providers in our population management efforts," says Gitomer, "and they get access to value-based contracts with payers that we have negotiated via the EHN."

To participate in the EHN, such providers must meet certain Emory requirements. They must have an electronic medical record that can interface with Emory's health information exchange, for example, and they must participate in Emory care coordination and other quality-improvement initiatives.

Medical homes: Another key element in Emory's strategy is what Patrick Hammond, EHN CEO, calls the "population management university," a training program that helps Emory practices learn the new skills required for population management and gain recognition as a medical home by the National Committee for Quality Assurance (NCQA).

In a medical home, care is team-based and highly coordinated, with special outreach to high-risk patients, such as those with chronic conditions like diabetes. The team works to ensure that patients fill prescriptions and take their meds and that they have the tools and understanding needed to take good care of themselves. Providers offer continuous, as-needed access, either in person or via the patient portal.

Emory already has two NCQA-recognized medical home primary care practices (one at 1525 and one in Dunwoody). According to practice transformation coach and RN Cathi Durham, 10 more are slated to come online next spring, with still others in the pipeline.

Durham meets monthly with the team in each of the 10 practices and conducts periodic all-day collaboratives to bring the teams together for education and networking. Their focus is continual improvement in quality and efficiency. "We help analyze practice service data so teams can get feedback on results, and we have software that soon will allow practices to pull such data themselves."

Emory is hiring two more coaches like Durham, each of whom will work with seven to 10 practices. "The goal is to have NCQA recognition for all 92 EHN primary care practices," says Durham. But getting recognition is not the end game because quality improvement is ongoing, she says, and it's also not just for primary care practices. Emory plans to create a medical "neighborhood" in which EHN specialty practices adopt characteristics of medical homes and receive NCQA recognition as well.

Value acceleration: There are other important elements to Emory's strategy in population health, including efforts by a team of experts, led by Gregory Esper, director of new care models, to define and redefine best practices one "clinical bundle" at a time—what Gitomer refers to as the "blocking and tackling" of health care. Esper's team is looking at a various questions: How can we coordinate better to facilitate earlier discharge from the hospital while also reducing readmission rates for at-risk patients? How do we implement evidence-based protocols across multiple surgical disciplines so that we can improve outcomes and reduce cost of care?

Building an infrastructure in population health may be painstaking and time-consuming, but it's already showing results, says Hammond. "We looked at our sickest patients, those who averaged 11 admissions and nine ER visits per quarter. After improving their coordination of care, these numbers are down to one each per quarter."

Coordinating care for veterans with dementia

Corrine Abraham, Anne Tomolo  

Faculty members Corrine Abraham (nursing) and Anne Tomolo (medicine) have worked together in care and training at the Atlanta VA Medical Center (VAMC) for three years now, and their latest collaboration is a new center to coordinate care for patients with dementia.

The Specialty Care Education Center of Excellence for Cognitive Disorders, co-directed by Abraham and Tomolo, is funded by a $1.5 million three-year award from the Department of Veterans Affairs. In addition to coordinating care, it will provide a platform for teaching Emory nursing students and medical residents and fellows and social work students from other schools as part of interprofessional teams.

"The center will help bridge the gap for patients by integrating telehealth and shared appointments with team members specializing in neurology, psychiatry, geriatrics, palliative care, and social work," says Abraham, who is coordinator of evidence-based practice and innovation in nursing at the VAMC. "Students will learn about specialty care for cognitive disorders with an emphasis on teamwork, collaboration, and quality improvement."

"It's important to have an entity that brings specialists and students together around patients and their families," says Tomolo, who is chief of quality medicine and site director for postgraduate training in quality and safety at the Atlanta VAMC. "The other crucial piece is integrating quality improvement into the curriculum so that students learn how to build a clinical model and improve practice together."

Currently, veterans with dementia enter the Atlanta VAMC through multiple pathways, either via their primary care physician or various specialists. The new center will consolidate their care.

Instead of being evaluated by different specialists in different locations at different times, veterans first will be assessed via phone by a nurse coordinator before they come to the VAMC for a clinic visit. Next, specialists in neurology, geriatrics, psychiatry, and eventually palliative care will decide as a group how to manage patients through shared appointments. After seeing patients, the care group will meet to develop a care plan and refer veterans and caregivers to VA and community resources. The nurse coordinator will follow up regularly by phone to help manage their care.

During clinic visits, nurses and social workers will meet with family caregivers to assess their needs. One option for caregivers will be Tele-Savvy, an online distance-learning education program for dementia caregivers developed by Emory nursing professor Ken Hepburn and colleagues. The program provides self-guided individual instruction and connects groups of caregivers for weekly chats online. Hepburn is now instructing center staff on using Tele-Savvy as an intervention.

"It's an ordeal to get a patient with advanced dementia out of the house to go to the doctor," says Abraham. "Tele-Savvy will provide caregiver support in the home and through peer-to-peer support, which will help caregivers cope with their loved ones' condition and manage their own anxiety and depression."

The center is currently in startup phase, and Abraham and Tomolo are immersed in hiring new staff, developing a program evaluation plan with public health faculty member N-goc Cam Escoffery, and piloting a curriculum for psychiatry residents from Morehouse School of Medicine, also a partner in the center. Other Emory faculty involved in the center include Nirmala Bangalore and Thomas Wingo, who lead existing VAMC clinics in mild cognitive impairment and neurology, respectively.—Pam Auchmutey

Emory to partner with regional big data hub


Emory will be a health care research partner in the new South Big Data Regional Innovation Hub directed by Georgia Tech and the University of North Carolina's Renaissance Computing Institute. The hub will serve 16 Southern states and the District of Columbia.

The hub is part of the National Science Foundation's four Big Data Regional Innovation Hubs announced earlier this month, formed to build public-private partnerships to address regional challenges through big data analysis.

Michael Zwick, AVP for research in the Woodruff Health Sciences Center, assistant dean for research in the medical school, and core director of ACTSI's research technologies program, will represent Emory on the South BD Hub Steering Committee.

A number of existing big data projects at Emory will collaborate with the hub.

Daniel Brat, Andrew Post  

For example, Daniel Brat, chair of biomedical informatics in the medical school and director of the Cancer Tissue and Pathology Shared Resource at Winship, is investigating biomarkers of human gliomas in an in silico Center for Brain Tumor Research, using large data sets such as the Cancer Genome Atlas. In a recent large national study led by Brat, researchers found that molecular diagnostics can be much more precise and consistent than traditional microscopic classification in diagnosis and prognosis of brain tumors.

Another hub collaborator in biomedical informatics is Andrew Post, interim director of ACTSI's Biomedical Informatics Programs. Post is leading efforts to create coordinated access to and management of clinical data across Emory and multiple medical centers in the Atlanta area and across the Southeast. A major component of the program is the i2b2 clinical data warehousing system at Emory and Morehouse School of Medicine. Post also leads ACTSI's efforts in the NIH-supported Accrual to Clinical Trials network, which includes more than 21 academic medical centers. Read more.

From the Executive VP

Responding to those in need

Michael M.E. Johns

When people need the Woodruff Health Sciences Center, we’re here—as illustrated by the 2015 community benefits report, Here in the Moment. The more than $67 million in charity care that we provided in 2015 to the poor, the uninsured and underinsured, and many others in need made a tangible difference in the lives of thousands of people.

And the benefits of our efforts aren't limited to the patients we serve; they also extend throughout our community in a host of positive and meaningful ways. All told, our research, education, and health care missions have a $7.2 billion impact on the community—in addition to the immeasurable value of providing help and hope to people in need.

As we enter the holiday season, I'm grateful that we have the opportunity to serve our community in this way, and I'm grateful for all the faculty and staff who make it possible for us to be here in the moment for all the people who depend on us.

Please direct questions and comments to evphafeedback@emory.edu.


In Brief

Nursing school ranks 4th in NIH funding

Linda McCauley, dean of nursing

The nursing school now ranks fourth in the nation in NIH funding. The school rose from 38th in 2009, with $1.9 million in NIH funding, to $6.2 million in 2015, the highest total in the school's history. Read more.

AED devices installed throughout campus


To help victims of sudden cardiac arrest, Emory has installed automated external defibrillator (AED) units in all Emory police cars and in 300 campus locations. Read more.

Cancer metastasis video wins AAMC top prize


A four-minute video starring Winship researchers has won first place in the AAMC's GRAND Basic Research video contest. The video features techniques for studying metastatic cancer cells developed by cell biologist Adam Marcus and graduate student Jessica Konen. Watch the video and see footage of one metastatic leader cell breaking off from a tumor and luring other cells to follow. Read more.

In addition to the researchers, collaborators on this video include Trish Haugaard (medical school Research Administration), producer Damon Meharg and co-producer Quinn Eastman (Health Sciences Communications), and medical animator Andy Matlock.

New funding to interest underserved kids in health professions


The medical school, in collaboration with Emory College, Atlanta Public Schools, and Atlanta Area Health Education Center, has received a three-year, $1.8 million grant from the U.S. Department of Health and Human Services to educate and expose high school students from economically disadvantaged backgrounds to career opportunities in health professions.

The Emory Pipeline Collaborative (EPiC) aims to prepare students from five Atlanta high schools for entry into health professions by increasing academic achievement, improving college readiness, strengthening social support, and broadening student awareness of pathways to health professions. EPIC will combine three existing programs, Emory Pipeline, Emory PREP, and Emory Summer Science Academy. Read more.

New inductees: Millipub and 1% clubs

Lily Yang, Kate Winskell

New Millipub Club members (authors of a paper with 1,000 citations):  

Medicine: Rebecca Arnold, Vasilis Babaliaros, Allen Beck, Tatiana Chernova, Cheryl Day, William Dixon, Chris Gunter, Lian Li, Bernard Lessegue, Zixu Mao, Ximei Qian, Tim Read, Mala Shanmugam, Shi-Yong Sun, Vinod Thourani, May Wang, Lily Yang. 

Public Health: Venkat Narayan, Saad Omer 

Emory College: Michael Crutcher, Justin Gallivan, James Rilling 

New Emory 1% members (those with grant applications ranked by NIH in the top 1%):

Medicine: Kathy Griendling, Hanjoong Jo, Hui Mao, Adam Marcus, Amir Rezvan, Alejandra San Martin, Raymond Schinazi, Stephen Traynelis, Lily Yang 

Public Health: Kelli Hall, Kate Winskell

Medical school selected for AMA training consortium

Bill Eley, Nate Spell

The medical school is among 20 medical schools recently selected by the AMA to join its Accelerating Change in Medical Education Consortium, which now has 31 schools. The schools will receive funding to better align medical education with the 21st century health care system. "We have been working for eight years to develop an innovative curriculum in patient safety and quality improvement," says faculty member Nate Spell, who is also chief quality officer at Emory University Hospital. Bill Eley (executive associate dean for education) is PI on the grant. Read more.


Kimberly Applegate

Kimberly Applegate (radiology) will receive the Marie Sklodowska-Curie Award from the American Association for Women in Radiology.

Jeannette Guarner, Robert Taylor

Jeannette Guarner (pathology) and Robert Taylor (cardiology) were recently inducted into the American Clinical and Climatological Association.


Nov. 19: Conversations with Digital Health CEOs. Forge Salon. 7-9 p.m., Georgia Tech Engineered Biosystems Bldg, Room 1005. More info.

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