PROVIDENCE – The Rhode Island Quality Institute is very much at the center of the vortex of health information technology in Rhode Island. It is a nonprofit entity, created in 2001 by then R.I. Attorney General Sheldon Whitehouse. It functions as a quasi-public agency, serving as the manager of the central databank exchange for patient data in Rhode Island.

Its board of directors are a veritable concentric circle enveloping the top leadership of Rhode Island’s health care delivery system: the CEOs of the largest hospital systems, Lifespan, Care New England and CharterCARE; the CEOs of the state’s four commercial health insurers, Blue Cross Blue Shield of Rhode Island, UnitedHealthcare of New England, Tufts Health Plan and Neighborhood Health Plan of Rhode Island; the CEOs of major physician groups, such as Coastal Medical and the R.I. Primary Care Physicians Corporation, the CEOs of the two major mental and behavioral health entities, The Providence Center and Gateway Healthcare; the leadership at government health agencies, including the R.I. Health Insurance Commissioner and the secretary of the R.I. Executive Office of Health and Human Services, the dean of the Warren Alpert Medical School, the CEOs of the R.I. Free Clinic and Home and Hospice of Rhode Island, and even the President of the Greater Providence Chamber of Commerce.

It’s a powerful group of industry stakeholders, to say the least. The Institute’s mission is to “significantly improve the quality, safety and value of health care in Rhode Island.”

The Institute very much creates a strategic framework for health IT policy and implementation through which government and industry can speak as one, collaborative voice.

Beyond CurrentCare
A major project that has defined much of the work of the R.I. Quality Institute during the last decade has been the development and implementation of the state’s health information exchange, known as CurrentCare.

The concept is that CurrentCare will serve as the central repository of patient data that can be shared across platforms to allow providers to view a patient’s medical records in real time, integrating the health IT data at the point of care, in order to avoid unnecessary and costly duplication of lab tests, imaging, and medications and, at the same time, improve the quality of outcomes.

There have been a few bumps along the road. To date, some 475,000 Rhode Islanders have chosen to enroll in CurrentCare, about half of the state’s residents, the total representing roughly 35 percent of all Medicaid members and 35 percent of commercially insured residents. One can view it as a glass half-empty or a glass half-full. One of the recommendations of the recent Reinvent Medicaid final report was to attempt to double the number of Medicaid members who enroll in CurrentCare, to some 70 percent.

In its first decade, the work of the R.I. Quality Institute has largely been supported by federal government grants. In the last few years, some of the funds to support CurrentCare have come from the state itself, a dollar per member per month fee on all Medicaid enrollees as well as all members of the state’s health insurance plan, as well as contributions from self-insured companies.

Another bump has been the high cost of achieving interoperability from providers using eClinicalWorks health IT software, which charges its customers a monthly fee for sharing its data with CurrentCare, according to Laura Adams, president and CEO of the R.I. Quality Institute.

That makes the cost of such data transfers prohibitively expensive for health care entities, including Coastal Medical and Thundermist community health center, which use eClinicalWorks. [Ironically, it was the R.I Quality Institute that once recommended the selection of eClinicalWorks as the preferred software for state providers. See links below to ConvergenceRI stories.]

In addition to its ongoing work on CurrentCare and the development of an online provider directory, the R.I. Quality Institute is also positioning itself to serve as a source for population health management analytics, according to Adams.

“I don’t necessarily feel or think that we should be the go-to place for [population health management] analytics,” Adams told ConvergenceRI in a recent interview.

“If you’re big, and you can layer on a sophisticated analytics system, and you are able, for example, to draw in all your patients’ data from CurrentCare, you’re probably pretty well positioned to do your own analytics,” she said.

If you’re not capable financially, Adams continued, “and you can’t afford that, there are certain kinds of analytics that we can provide, which will be less expensive for us to do than for providers.”

Adams said that they were hopeful about the potential to receive another grant for a predictive piece of analytical modeling, one that would sit atop the dashboard that the R.I. Quality Institute has been developing for individual entities, such as Thundermist.

The dashboards enable the providers to set up and watch the data, at regular intervals. “At this point, we can tell you, someone’s high risk because they’ve been admitted multiple times at the hospital,” Adams explained. “But that’s all rearview mirror.”

The new predictive analytics modeling will be able to tell providers, she further explained, “That this [patient] is on a trajectory, so that if interventions don’t happen, you’re going to add another high-risk patient to your [population being served.]”

Both the dashboard work and the analytics will be done on a fee-for-service basis, enhancing the revenue stream of the Institute.

Here then, is the interview with Laura Adams, president and CEO of the R.I. Quality Institute, and her colleague, Alok Gupta, the chief operating officer and chief information officer.

ConvergenceRI: Congratulations on all the recent grants you have received. I wanted to go back a bit and find out where things stand with CurrentCare. I saw a recent email that said that the current level of enrollment was 475,000. What do you need to do to get to the next level of enrollment?
ADAMS: We’re looking at what that 475,000 means. It isn’t a random 475,000; it’s the 475,000 that interact the most frequently with the [health care] delivery system, because that’s where you get enrolled, when you interact with the delivery system.

I think we might be beginning to think a little differently, not that we don’t want eventually everyone enrolled. But, I think as we’re beginning to look at [providers] with high-risk populations, with ACOs [accountable care organizations] that now are responsible for the care of heart-failure patients, for example, with bundled payments, where we’re beginning to work more closely with providers about making sure that 100 percent of certain groups are involved – the ones that probably need CurrentCare the most.

So, we’re definitely thinking along the lines of getting to the million we’d like to see enrolled.

People still suggest that, if consumers knew more about it, they might speak to their doctor about this CurrentCare and get enrolled.

We’re working on more innovative kinds of campaigns – when doctors send out their reminders that it’s time for your XYZ exam, and, by the way, we’d like to make sure that if you haven’t enrolled in CurrentCare…

So, [the message will be] tagged onto a routine conversation that physicians have.

What we’re finding is: most physicians don’t mass email their patients.

It’s getting to be more and more, but we struggle every day with reaching consumers in ways other than snail mail, and we don’t have the budget for billboards and TV ads, things like that.

ConvergenceRI: Going back to 2009, and maybe before that, you were able to reimburse providers, as part of the Beacon grant, I think it was $3 per enrollee, and that created a certain amount of momentum and push toward enrollment. Without that reimbursement, with providers no longer getting paid to enroll their patients in CurrentCare, is that part of the reason for the slowdown?
ADAMS: You know, when we removed the payment, we expected to see a decline, visible and attributable; but we didn’t.

We found that [loss of the reimbursement] to be not as relevant, almost to our chagrin. We wondered how much earlier we could have stopped the payment.

I think it has more to do with a bit of a saturation level of those who come through the door of the delivery system.

GUPTA: That’s true. The value of CurrentCare is more than the $3; providers have seen the increased value of enrolling their patients in CurrentCare, so they don’t need an extra incentive.

ConvergenceRI: One of the goals that came out as part of the final report of Reinventing Medicaid was that they wanted to increase the number of Medicaid patients who were enrolled in CurrentCare to something like 70 percent. Which, of course, made me wonder, and ask: what is the rate of enrollment now? That number, according to the R.I. Executive Office of Health and Human Services, was 35 percent.

When you subtracted the Medicaid enrollment numbers from the total of the 475,000, it showed that the rate of enrollment was 35 percent for Medicaid and about 35 percent for what I’ll call the commercially insured group.

How do you get the Medicaid population to move if you haven’t been able to move the commercially insured population? Is there a different strategy?
ADAMS: We almost do have half the population, so we’ve gotten, I think, a fair amount with very few dollars. We certainly haven’t done any marketing; you haven’t seen any billboards, any ads to raise awareness.

But we do think there’s a different approach to use to enroll the Medicaid population. We’re working now with Medicaid so that when they interact with recipients at the state level, there’ll be some kind of conversation at that point. Certainly, when they enroll them into the program, there will be a conversation.

Now, in this state, we do have a law that says enrollment is voluntary, I think that’s well known to people.

I know the state’s concerned, because of all the people they would like to see enrolled, it’s their Medicaid population, because of their needs and because of what a huge percentage of the state budget that [Medicaid spending] is.

We are working with the state to come up with different strategies for where they might be able to deploy some of their own resources.

We’re still continuing to work in the provider arena.

I think there is some possibility, when the new guidelines come out for what a Medicaid ACO looks like, if you want to qualify to become one of those, I have a feeling that there’s a good chance that there will be something in there around about the way that you’ll be actively engaged in CurrentCare.

ConvergenceRI: I have heard rumors of a Medicaid ACO being developed here in Rhode Island; are you privy to the same rumors?
ADAMS: We don’t know a whole lot, except to say that the state has put out an RFI [request for information] saying, if we were to certify these ACOs, what should be in the certification requirements.

ConvergenceRI: To push back a little bit, even though they all may not be enrolled, the state pays $1 per member per month to CurrentCare for every Medicaid member enrolled. There’s also a similar fee assessed on behalf of all state employees, whether they are enrolled or not. Do you think this is a good way for the state to fund CurrentCare? Are there better funding mechanisms?
ADAMS: I think that there are other alternatives that could be developed in looking at that. Think of the state’s return on investment of a dollar per member per month. If they prevented just one duplicate lab test for one Medicaid enrollee, they could put two Medicaid enrollees in the plan for a year. So, the bar is pretty low.

If they prevented another ED admission, another hospitalization, they could pay for a whole lot of Medicaid recipients to be in CurrentCare. We do think it’s a very low bar for ROI.

It doesn’t meant that there wouldn’t be other ways they may elect over time to fund it.

ConvergenceRI: Switching gears, it was announced recently that you had received an award of $8.3 million over four years from the Centers for Medicare and Medicaid Services for work on the efforts around what’s known as the Practice Transformation Network. How will that work be coordinated with Healthcentric Advisors, the Quality Improvement Organization for most of New England?
ADAMS: It was actually a federal requirement we align with the QIO activities. They were part and parcel of this grant. They were not eligible to apply for it, but they were required to enter into a support arrangement.

That was not through our grant, but it was through CMS saying: you won’t be applying for these, but you will be supporting the work.

So, we think that those [efforts] are going to be hand in hand.

ConvergenceRI: Within the framework of that grant, will you build the internal support here, and hire new staff to do the work? Or will you contract out?
ADAMS: Unlike some of other grants, where we needed to engage with a technology company, and significant money went out to that tech company, this is quite different.

When CMS began the early conversations with us as a finalist in the application stage, they made it clear: we’re developing a cadre of experts nationally, and we are going to expect you to draw heavily on this. We’re developing what’s known as change packages, [based upon the] science around getting these outcomes to be improved.

In many ways, if you remember back to our ICU project, we had many change packages to make sure that every patient gets these five interventions to help prevent central line infections.

[CMS is coming to us] with this big change packet set, saying: you’re to help embed this science of improvement and these practices.

[At first], we thought we would be bringing in a lot of local experts and maybe a few experts from out of town, but they were very clear: they want us to be a conduit for a national set of experts.

ConvergenceRI: So, you won’t be making a lot of investment in your own internal infrastructure, is that correct?
ADAMS: That’s right. I think, for the most part, the staff needed to execute and drive those change packages and help the practices become capable of management by metrics, that’s what we’ll use the staff here for.

ConvergenceRI: I’ve heard rumbles that many of the practices and providers are really tired of practice transformation, that there’s a real burnout factor. It seems like it’s another hurdle for the way to change how providers are practicing medicine and conducting their business.

How is practice transformation related to the trend that the single practitioner is going away, and the trend is toward consolidation into larger group practices?

Does practice transformation presage the shift from fee-for-service toward the bundled payment model, and with it, the consolidation into fewer practices?
ADAMS: No, I think that the good news about this grant is that [the money] is not allowed to be applied to those that have had a lot of transformation support before.

It’s a brand new crop, it’s for all those who did not get assistance under any other federal initiative or through the Care Transformation Collaborative.

I think what the federal government has in mind for the goal [of this initiative] is that practices become capable of participating in the new payment models, however that looks.

Whether you agree to be bought up by somebody, whether you agree to come in as an independent group, and whether you’re going to be part of this ACO or that ACO.

Fortunately, providers will be able to become involved in several different ACOs; I think there are some restrictions on hospitals. Providers in the community can participate in more than one ACO.

[For instance,] I believe that a statewide orthopedics group is forming. That’s one way for consolidation to happen.

ConvergenceRI: That’s what I was asking. If you are an individual orthopedic surgeon, how do you compete with a statewide orthopedics group?
ADAMS: Yes, I think that’s going to be hard.

ConvergenceRI: There was a survey recently released in March of this year, but conducted in 2013 by the R.I. Department of Health, with findings about that the way that physicians were using electronic health records. More than 80 percent said that were not signed up to use CurrentCare, of if they were, they were not using it.

I have heard some people criticize that survey, saying it was out of date. My understanding is that there was a new survey conducted earlier this year. None of the results have yet been published, is that correct?

ADAMS: I think that the new survey should be out soon. I think that – I know that it’s been completed and they are doing the final analysis, getting ready to present it. I can’t speak to when they will release it.

ConvergenceRI: Have you seen it?
ADAMS: We’ve seen some preliminary numbers, yes. We’re not seeing a whole lot of change in the numbers.

And, our sense about that is, it is what we expected, in the sense that it was a survey of all physicians in Rhode Island.

I mentioned that the grant that we just got is for this entire constituency of physicians, [many of whom] we’ve never had conversations about CurrentCare with.

This was a survey conducted of the whole population of physicians; what we’re finding is that the usage of CurrentCare is accelerating most rapidly around nurse care managers, and among other team members, that are responsible for quality improvement and quality reporting.

We still measure logins, as in how many people log into CurrentCare. What we realized was that the number was problematic, because you could log in and look at 30 charts, and it would be counted as just one log in.

We also realized that when physicians say that they don’t use CurrentCare, it could be very well that their nurse care manager uses it every day.

Also, that survey doesn’t count alerts, it just counts one component of CurrentCare, not another component of CurrentCare.

Our concern with that survey now is that it is [calculating] one set of metrics, around how CurrentCare is used, and there are about five or six different ways that you can use it now.

For example, we have heard from providers for a very long time, we don’t want to sign out of my system to sign onto your system to get to your portal.

At Care New England and at Lifespan, at places where there is an Epic [health IT] installation, at [health entities] where there’s a NextGen installation, or where there’s an Athenahealth installation, providers don’t have to leave their system.

You can click on a button, so, in many cases, the provider may not even know that they are drawing in CurrentCare data.

We understand the use and value of the that HIT survey, but it doesn’t measure who is using alerts, or the new dashboard that we just debuted at Thundermist that brings in all of that alert data in a real-time fashion, right in front of the nurse care manager, updating every 45 minutes, as to who’s in the ED.

That’s another usage that is not counted in that survey.

ConvergenceRI: Do you expect that this new sign on can be used throughout all systems? Are there still interoperability problems with eClinicalWorks? Has that been worked out?
ADAMS: It’s not a technical interoperability problem. It’s how much eClinicalWorks is charging its providers to release the data.

We do know that there is some concern nationally around what’s known as informational locking. I don’t know if this would necessarily fit under that rubric; I do know that we’re not the only place in the country with a gap in our collecting up of information from patients.

The patient data from Coastal Medical and the Thundermist system does not flow into CurrentCare. The charges for that are quite substantial for them to release the data. They are the only [software] vendor charging their customers to release data to the health information exchange.

GUPTA: It’s not a one-time connectivity charge. It’s an ongoing, every month charge.

ADAMS: Our local providers are very frustrated that they are not able to join in on this because it’s so cost prohibitive.

There was some sense that we might have wanted to do something locally about that. I think we’ve recognized that it is a national problem with that particular vendor and what Rhode Island is able to do alone will not be as effective as what [on the national level] can be organized. 

ConvergenceRI: Isn’t it ironic that, at one point, Rhode Island tried to come up one software package for all providers, and you recommended eClinicalWorks, and it turned out that this one package was not geared toward interoperability?
ADAMS: Don’t you think it’s a lesson learned for those who think we should be putting all our eggs in one basket? You just can’t predict what direction your vendor is going to take. Because this is policy decision by eClinicalWorks, it’s not about technology capability.

I do think it’s a lesson learned, before you decided that everyone ought to be going with one vendor.

ConvergenceRI: Do you still find that the model for CurrentCare, with one central state repository for all patient information, so that all data flows through you, and then you share it, is the most cost-effective, efficient way to manage the data flow? Is there a better model that may be more nimble, such as Health Information Service Provider [HISP] connecting directly to Health Information Service Provider?
ADAMS: We see a lot of this point-to-point connection, because of lot of people did this, and it’s next best solution to [a centralized state health information exchange].

The problem with all those direct connections is that, as a provider, you’ve got to know where all [the patient’s] information is, so you can call out to each one of those systems, each one brings back a separate [report], and your job is to go through the [reports] and try to make sense of it.

That’s the problem with a point-to-point connection, it doesn’t have the ability as a functionality to show the labs with the labs.

When you connect to CurrentCare, you don’t have to know where they’ve been. If that patient has consented, the patient’s data is there, even if they forget where they’ve been.

The data is also all parsed, the labs are with the labs, the meds are with the meds, the history is over here, and the behavioral health information is behind this wall.

ConvergenceRI: Within the State Innovation Model grant, I believe that you are involved in four or five different projects, including the provider directory. What’s happening with the provider directory? When will it make its debut?
ADAMS: We didn’t realize when we first started to develop it, that we had another HIE thing on our hands. What we mean by that is this: everyone can do point-to-point connections, but the cost of building and maintaining a system where everyone is connecting to everyone is so much more expensive than saying, I can connect in once, and everyone can go it and get it from that source.

It’s so much cheaper that way.

When we began to look at the provider directory that we were enabling, our board started to say: how are you building that thing?

We said: it’s not jut one or two sources of data, it’s like an HIE, we want multiple sources of data coming in so that this [directory] is the absolute source of truth, the best, the most up to date, the most accurate source.

I think it was Tim Babineau [the CEO of Lifespan] who said, I’ve got a number of these things running, we struggle to keep them up to date. There’s not a competitive edge to me having an up-to-date provider directory. In fact, it’s something in common that we all need. Could we do this as some kind of shared utility?

That was a great idea. Then, as we did the planning, which is part of the reason why it’s taken so long to bring it up, we’re the first in the country to hook in such things as, we wanted to know not only where the doctor is located, we wanted to know what health plan they are affiliated with. Are you in this ACO? Are you in that model of payment from Blue Cross? Are you in a patient-centered medical home?

And then, we had to build all the different connections. For example, Lifespan, if they gave us a data feed, was it the absolute best, up-to-date data feed on Lifespan people? We need it from CharterCARE; we need it from Care New England.

Everybody agreed that this was a really good idea, build it once, and we may be able to take down the numerous provider directories that are being funded in the state, all of which are not necessarily up to date and hard to maintain.

ConvergenceRI: What happens when a patient attempts to find a provider, say, a dermatologist, only to discover that all the dermatologists listed on a health plan’s provider director no longer see patients with that coverage?
ADAMS: I don’t know if we can sort that out

ConvergenceRI: If they are on the provider list, and it says they should be, and the plans says they should be, but they are unwilling to take patients from that health plan, is there a way of having a feedback mechanism?

It’s possible that what the hospital wants and the provider wants and the health insurer wants in a provider directory may not be what the customers want.
ADAMS: I think we have an opportunity when we bring this up, and we make the consumer portal open, and we can build all kinds of ways that consumers can give their feedback.

ConvergenceRI: What is your business model, moving forward, for generating a revenue stream? In the past, you have often seemed to be dependent on federal government grants? Do you envision weaning yourself from such grants?
ADAMS: Our business model has been a hybrid model, a three-pronged model, which is grants, the per-member-per-month fee, which is voluntary, and fee-for-service.

When we look at grants, if we can continue to stay out front and innovative and be the first place that the federal government wants, [we believe that] the money will flow in here first.

We’re very careful with our grants model that whatever grant we [apply for and]get, it is aligned with what we are supposed to be doing, providing for our community to assist in health reform. We don’t try and go after things that are not our business.

As long as those funds are available, I think we have a pretty good shot at being able to pull in federal money. Grants will probably be, for the foreseeable future, a part of our revenue model. I don’t know if there is a need to wean us off of grants.

The second prong is the pmpm. That’s going along quite well, we’ve got companies that are participating in that, we’d like to have more, for sure. But that’s going quite, quite well.

The next area is the generation of revenue through fee-for service.

GUPTA: For analytics, for selected providers, not for everyone, we can get the data and do what we do for the Care Transformation Collaborative, where we do quality measurement.

It’s not a service that we provide to everyone in the state.

ADAMS: If you want one of those data feeds out of the provider directory, it won’t be free. That data feed is a fee for service, because we are making the change from everything we do is free, to “if what we do for you benefits you in a special way, there’s going to be a cost associated with that.”

We put everyone on notice at the beginning of our provider directory development that we didn’t intend to make it so much like the HIE, in the sense that people can access the HIE for free.

Dashboards aren’t free, because we put your patients on the dashboard; that’s another example of a fee-for-service component.

ConvergenceRI: Is the R.I. Quality Institute positioning itself to become the go-to shop for analytics?
ADAMS: I don’t necessarily feel or think that we should be the go-to place for [population health management] analytics.

If you’re big, and you can layer on a sophisticated analytics system, and you are able, for example, to draw in all your patients’ data from CurrentCare, you’re probably pretty well positioned to do your own analytics.

If you’re not capable financially, and you can’t afford that, there are certain kinds of analytics that we can provide, which will be less expensive for us to do that for providers.

We are on the verge of receiving a grant for a predictive piece of analytical modeling, one that would sit atop the dashboard [monitoring hospital alerts]

At this point, we can tell you, someone’s high risk because they’ve been admitted multiple times to the hospital. But that’s all rear-view mirror.

This modeling capability will be able to tell providers that this [patient] is on a trajectory, so that if interventions don’t happen, you’re going to add another high-risk [patient to your population being served.]

ConvergenceRI: How will your new analytic focus address the social and economic determinants of health, and health equity? And the fact that what your zip code is often determines what your chances are in leading a healthier, longer, happier life?
ADAMS: Because we’ll have a new way of looking at this information, we will be able to look at populations and say, how many people enrolled in that zip code, we will know admissions, discharges, doctors’ visits.

I think we are going to be able to get a much more complete picture at our finger tips about access to care, and what kinds of care they get after they access care. And, are their rates for this or that procedure lower than other populations, even though their diagnoses are the same.

Brown’s been quite excited about CurrentCare as a potential research vehicle. These are things we’re going to be able to query the database about. And, the good news is, if you’re uninsured, now, you can be in Medicaid, tomorrow, you can be in Medicare the next day, none of that stops data from flowing in.