Delivery of Care

Taking the pulse of primary care in the age of the ACO

Dr. Al Puerini of Rhode Island Primary Care Physicians talks about his decision to join Care New England’s new ACO, Integra, and the reason why his own EHR software product, EpiCHART, will soon fade away

Photo by Richard Asinof

Dr. Al Puerini, chairman of the board of directors of the Rhode Island Primary Care Physicians Corporation, an independent practice association founded in 1994, talks about the decision to align with Care New England's ACO, Integra.

By Richard Asinof
Posted 6/8/15
The alignment of the R.I. Primary Care Physicians Corporation as a fundamental building block in Care New England’s new Integra ACO demonstrates the kind of sea change that is taking place in the health care delivery system in Rhode Island.
How will the efforts to create collaborative, community-based Health Equity Zones become part of the conversation within the care transformation efforts underway with patient-centered medical homes in Rhode Island? How will the introduction of smart phone technology to share information and data in real time change the equation? How will the growing role of nurses, nurse practitioners and nurse care managers be reflected in the corporate decision-making of hospital systems? How will the patient change the conversation with health care providers to be able to “talk back” about meeting their needs, and not just meeting the doctor’s needs?
The effort to develop a network of neighborhood health stations in Rhode Island continues to gain traction, with Dr. Michael Fine, the former director of the R.I. Department of Health, announcing a kickstarter campaign to help fund the full development of such a neighborhood health station in Central Falls. Fine is also now working in coordination with the Scituate Health Alliance.
In an unrelated matter, the closing of six group homes by Gateway, part of the Lifespan network, has raised the question of whether those homes – and apparently a seventh in Newport – can be “recovered” and be repurposed by the recovery community in Rhode Island.
Finally, in a third, unrelated matter, there is a news conference scheduled for Monday to discuss the problem with the R.I House’s version of the Good Samaritan law reauthorization, which limits protections to those who call 911 to report a drug overdose, unlike the R.I. Senate’s version.

CRANSTON – When it comes to primary care in Rhode Island, Dr. Al Puerini has been a pioneer in reshaping its health care delivery practices.

In 1994, Puerini helped to create the R.I. Primary Care Physicians Corporation, one of the first independent practice associations of primary care physicians in the state, aligning some 30 doctors and their practices. Two decades later, the groundbreaking association now counts 150 physicians as members from 130 practices.

R.I. Primary Care Physicians now has the largest number of patient-centered medical homes, or PCMHs, in the state, with more than 100, according to Puerini.

R.I. Primary Care Physicians also created its own electronic health record system 12 years ago, known as EpiCHART electronic health record system, in response to the health IT data needs of primary care physicians.

But now, as much of the health care delivery landscape shifts dramatically, Puerini is once again in the role of pioneer. He has led 115 of the 130 primary care practices in R.I. Primary Care Physicians to align themselves with Integra, the new Care New England accountable care organization, or ACO.

With that move, R.I. Primary Care Physicians has also made the difficult choice to move away from EpiCHART and to adopt Epic as its health IT system, with the support of Care New England. The move to go live to Epic is scheduled for next week, according to Puerini.

Further, there is a pilot program now underway at Kent Hospital to connect doctors in the Emergency Room in real time with R.I. Primary Care Physician practices through smart phone technology, using technology developed by Care Thread, an early stage Rhode Island company.

ConvergenceRI sat down to talk with Puerini at one of his favorite “offices”: T’s Restaurant in Cranston on Park Avenue one morning last week, in his favorite booth, over coffee and a healthy, appropriately portion-sized breakfast.

Here is the interview, a follow-up story to last week’s conversation with Domenic Delmonico and Dr. James Fanale: “Care New England talks about its new ACO, Integra.”

ConvergenceRI: How did your role with aligning in Care New England’s ACO, Integra, evolve?
PUERINI:
It has evolved. Rhode Island Primary Care Physicians now has 130 primary care physicians. When we incorporated in 1994, our role [as an independent practice association was to help small primary care practices that were kind of getting lost in the shuffle in the mid-1990s.

We formed a group that started with 30 docs and has now grown to 130. We shaped the contracts [with payers], we worked hard on education, trying to help [doctors] practice more quality medicine, better medicine.

We’ve been very successful; our docs do very well and the quality is very high. All of our incentives for the bulk of our contracts are based on quality. We’ve done very well with Blue Cross [& Blue Shield of Rhode Island], with United[Healthcare], with Tufts.

But, you can only go so far with primary care. We only control, directly, about 10 percent of the health care dollar. And, if we really want to make an impact on the system, which we do, we needed to partner with a larger entity.

I started going around and meeting with Lifespan, CharterCARE and Care New England. I met with all the CEOs over the course of a year.

We settled with Care New England, mainly because of their philosophy, which was very physician-centered, primary care-centered, patient-centered.

They had an understanding of the importance of primary care as the foundation of any good health care system. Dennis Keefe [the president and CEO of Care New England] has been tremendous to work with.

When we decided to partner with Care New England, [the conversation around an ACO] became more prominent.

I said: I’ve got 130 docs, you’ve got a bunch of hospitals, we’ve got a potential system here that could become a virtually integrated health care system, which is the best you can do in Rhode Island.

ConvergenceRI: Why not a fully integrated system? Why is that?
PUERINI:
Until you have everyone working for the same entity, that’s not going to happen here.

My group portrays [that sense of independence], because our docs are hugely independent. In joining our primary care practices with the Integra ACO, they can still maintain their independence, and they still submit under their own tax IDs.

We make recommendations, but they don’t have to follow them. Because of what we’ve done, they have a lot of trust and confidence in what we do. As a result, we can move forward a little quicker, and we formed the entity, Integra; 115 of my docs signed up.

The only ones that didn’t were the docs that were older or getting ready to retire. Some of them didn’t want to get an electronic health record system, with is a requirement of the new ACO. Getting 115 out of 130 was pretty good.

So, we clearly made a huge primary care base for Integra. Care New England has about another 50 primary care docs throughout their system. Most of those are joining; once again, it’s voluntary.

We formed Integra with the intention of really putting together an entity that can service patients, from birth to death, soup to nuts.

We’re trying to form relationships with other hospitals, other skilled nursing facilities, with home care associations.

ConvergenceRI: Are there places where the new ACO system needs strengthening?
PUERINI:
One of the cogs in the new system is the relationship between primary care physicians and emergency room docs, and that has eroded a little bit [recently].

Mostly, it’s the PCP docs’ fault, because we don’t go to the hospital anymore. We focus our attention on outpatient medicine, which is what we do best, and let the hospital focus on inpatient medicine.

Because of that, over time, it’s brought us away from the hospital, and the channels of communication have eroded. We’re working on that now.

We are putting in place pilot programs to enhance communications between the ER docs and PCPs.

ConvergenceRI: What are the pilot programs?
PUERINI:
We are doing a couple of things at the same time. First, we are placing nurse care managers in the emergency rooms, who serve as the liaison between the emergency rooms and the PCPs.

We also have a pilot program that’s going to use smart phone technology, working with a company in Providence called Care Thread. [See link to ConvergenceRI story below.]

The pilot program will be with 30 primary care docs and the emergency room at Kent Hospital. That’s where we’re going to start.

Hopefully, if it works, we’re going to expand to all our PCPs and to the emergency room at Memorial Hospital.

I think it has a lot of potential, because the primary care doc will know when your patient is in the emergency room before the emergency room doc even sees your patient.

As soon as the patient is registered, we’re going to get notified, and it will trigger me, as a PCP, to send the patient’s important information to the emergency room, so that when the emergency room doctor is seeing the patient, he or she is not shooting from the hip.

ConvergenceRI: How will that data interface with your EHR system, EpiCHART?
PUERINI:
EpiCHART is going away. Initially, the transfer of data between the emergency room and the PCP is going to go just through the smart phones. [Care Thread] has in place a system, which we’re not going to use right away, where we can actually transmit information from the electronic health record.

But, initially, we will be able to at least fax a patient summary report, which includes a patient problem list, a medication list, allergies, and recent test results.

Not to mention that the ER docs will now have a direct link to me, so they can text me and I can get to them as quickly as I can. It puts your right there, on the spot, in real time.

ConvergenceRI: How is that different from what CurrentCare currently provides?
PUERINI:
I was originally a naysayer, but I think that CurrentCare has begun to come around, particularly with CurrentCare alerts.

My nurse care manager can go in, in the morning, and on the basis of CurrentCare alerts, she can go and begin to communicate with those patients [that have been seen by an emergency room].

The difference is that, with CurrentCare, it’s not in real time. With smart phone technology, I can be in touch, just like that.

They are not mutually exclusive; they are both valuable systems. On is for ER treatment, on the spot, and the other is for more general follow-up, an acknowledgement of where your patients are.

ConvergenceRI: Why is EpiCHART going away?
PUERINI:
It was a wonderful system, we created it ourselves; it was developed by our primary care docs. So, obviously, it was very user friendly, because it had all the features that primary docs wanted.

But, we’re a small company, we can only take this so far. We’re not a cash-rich organization.

When we made the choice of aligning with Care New England, we realized how important it was to interface and get information throughout the system. And, they went with Epic.

We made the decision at the board level. We asked first, could we get EpiCHART to that level, and then, could we interface with Epic, and the answer was: probably not. We decided to go with Epic, and Care New England is supporting the transition.

All of the docs are transitioning to Epic. We have about 80 docs on EpiCHART, the rest are on a smattering of [products]; eClinicalWorks, Athena, systems like that.

When everyone has migrated over to Epic, the transfer of information will be great. And, not just in the Care New England system, but with Lifespan.

ConvergenceRI: Is there going to be interoperability between the Epic systems at different hospital systems?
PUERINI:
Yes, that is required by Epic. Epic mandates that if you have Epic, you have to share information with other systems, as I understand it.

Basically, if I have a patient in California that’s been seen by a provider that’s part of a system that uses Epic, I can get their information. I haven’t seen that yet; we’re going live next week.

It was a difficult decision [to phase out EpiCHART.]

ConvergenceRI: Was it like letting go of your baby?
PUERINI:
It was kind of like that. It was something that you’ve worked on for 12 years, and now, despite the fact that all our docs rally liked the system, we knew that if we want to take things to the next level, that we have to move on. It was a difficult decision, but we thought it was the best decision for care coordination.

ConvergenceRI: Can you talk about the problem with primary care providers being poorly reimbursed, compared to other providers in Rhode Island?
PUERINI:
It’s national, and not just Rhode Island.

ConvergenceRI: For all the new emphasis on primary care, what will it take for the rates for primary care physicians to increase, so that Rhode Island’s rates are comparable to the rates in Massachusetts?
PUERINI:
That’s a good point; we’re low man on the totem pole financially in the health care delivery system. Everybody’s aware of that. It’s been a struggle, but it’s improving. Primary care is getting more attention, thanks to Chris Koller [the former R.I. Health Insurance Commissioner. He was a champion of primary care. He really started the movement in Rhode Island with the Chronic Care Sustainability Initiative.

We had Dr. Michael Fine as director of the R.I. Department of Health for four years; he’s a primary care doc. And the new agency director, Dr. Nicole Scott-Alexander, is also a primary care physician.

The biggest problem in health care is poor communication – between clinical providers, hospitals, nursing homes, and home care agencies. We’re all working in our own little silos. And, we’re not communicating.

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