PROVIDENCE – Maybe it was all the noise surrounding Buddy Cianci’s entrance into the 2014 Providence mayoral race as an independent, with the news media flocking moth-like to the brightly manipulated glow.

Or, the hoopla created to celebrate calamari becoming Rhode Island’s official appetizer.

Perhaps that’s why no one paid attention to this significant economic news: Moody’s Investors Service downgraded Lifespan’s bond rating to Baa2 – only two notches away from junk bond status, according to a report in Modern Healthcare.

Lifespan, Rhode Island’s largest private employer, had its credit “dampened” because of its $100 million investment in the installation of Epic, the health IT electronic records system.

Moody’s also cited Lifespan’s poor ongoing economic performance: Lifespan is projecting a 2.8 percent operating cash flow margin for FY 2014, which is far below the Baa2 median of 8.8 percent. The operating margin was predicted to be around -1.7 percent.

Executives were reported to tell Moody’s they don’t expect to post improved results until 2016, according to the blog, Health Care Renewal.

“The thin performance provides little cushion during a period of increased capital spending and the installation of a new IT system with short-term implementation risks that could disrupt cash flow,” according to the Moody’s report.

Lifespan’s response is that they are applying “best practices” to their $100 million Epic implementation.

“Understanding the inherent risk with IT conversions, Moody’s chose to take a conservative approach that was reflected in our recent downgrade,” Gail Carvelli, Lifespan spokeswoman, told ConvergenceRI. “We are applying best practices to our Epic implementation to minimize the impact on cash flow.”

Lifespan was, not surprisingly, very quiet about Moody’s downgrade of its bonds. It has also been rather quiet about its cost-cutting regimens, such as creating an in-house provider network for its own employees, charging co-pays for those who seek care outside the Lifespan system. [See link below to ConvergenceRI articles.]

But Lifespan did tout recently its new bundled payment initiative with Blue Cross & Blue Shield of Rhode Island, to adopt an accountable care organization model, one of several new risk-sharing efforts now underway in Rhode Island. The new three-year plan covers about 35,000 insured patients being seen by primary care providers. Instead of fee-for-service, physicians will be rewarded for how closely they follow evidence-base practice protocols – say aspirin for cardiac patients – measurements to be captured by the hospital’s IT system. The move is said to reflect the changing business model for hospitals in the post-Copernican world of health care reform, designed to incent physicians to make better use of IT system 

The question: how does Lifespan’s investment in the new $100 million Epic health IT system get translated into the calculation of shared costs to the patient being treated?

The metrics of health care IT
Lifespan’s application of best practices may not resolve more fundamental questions now in play about financial investment strategies in health care IT systems:

• How will such a massive investment in a hospital system’s IT infrastructure move the needle on patient-centric and patient-directed care?

• Is it cost-effective as a way to control escalating costs?

• Are there better, more nimble ways to manage population health analytics, a key component in the bundled, global payment model, at the point of care?

• Will a cloud-based, more mobile-friendly health IT system overtake Epic in the marketplace, making the Epic system, based on the clunky MUMPS software platform, obsolete?

• If the overall goal is interoperability across all health systems in Rhode Island, are there more cost-efficient methods to configure the viewing, pushing or pulling of data in between systems?

• Where does the patient fit into this conversation?

The underlying value proposition that electronic health records are the way to drive costs down and improve health outcomes still needs to be validated in the marketplace.

Despite the promise of better coordination of care, reduced readmissions to hospitals, reduced need for unnecessary tests, and better metrics to measure performance, sometimes conversation and patient engagement can trump technology prowess and protocols.

As Dr. Leana Wen wrote recently in her essay, “Heart of the Matter: Treating the Disease Instead of the Person,” describing the opposing views of the patient and the caregivers successfully dealing with a heart attack: “In modern medicine, we are fortunate to have incredible high-tech options available, but we must not forget the low-tech approaches that can improve communication and quality of care.”

The objective measures that health care workers focus on are necessary, she concluded, but they’re not enough by themselves. There is a difference between treating a patient “as a disease to be cured, not as a person to be cared for.”

IBM vs. Apple, redux?
Lifespan is not the only big health care system to embrace the Epic health IT system, headquartered in Verona, Wisc., just outside of Madison. In Rhode Island, both CVS and Care New England have also recently announced they are moving to the Epic platform, as have many large hospital and health systems, including Partners Healthcare in Boston, the largest hospital system in Massachusetts.

The desired goal is to achieve a fully integrated record for all aspects at all sites, in line with the changing rules under health care reform and the shift toward global capitated risk management that are required to maintain continuous wellness, according to Dr. John D. Halamka, the CIO at Beth Israel Deaconess Medical Center.

In his July 2013 blog, “Life as a Health Care CIO,” Halamka wrote: “In my experience, hospitals are now willing to give up functionality so that they can achieve the integration they believe is needed for care management and population health.”

In contrast, Halamka believes that building core components of EHRs for clinicians using a cloud-hosted, mobile friendly, highly interoperable approach offers lower cost, faster innovation, and strategic advantage.

“We may be the last shop in health care building our own software,” he said.

Halamka posed a number of prescient questions: Will the total cost of Epic’s system become an issue for struggling hospitals? Will the fact that Epic has been slow to adopt mobile and web-based approaches prove to be a liability? Will a competitor to Epic emerge, such as Athenahealth, with its agile, cloud-hosted system?

Or, will Beth Israel Deaconess and Boston Children's hospitals be the last academic medical center bastions in Eastern Massachusetts that have not replaced their entire application suite with Epic?

In what he called “the era of Epic,” Halamka likened himself to the last holdout from the alien invasion in the classic film, “Invasion of the Body Snatchers,” fighting off becoming a pod person. “At times, in the era of Epic, I feel that screams to join the Epic bandwagon are directed at me.”

Another side of health IT
To date, the most sophisticated use of health IT at the point of care in Rhode Island has been achieved not by hospital systems but by a community health center, Blackstone Valley Community Health Care. Over the last four years, they have bent the medical cost curve by $12 million, a remarkable achievement given fact that they serve about 15,500 patients from mostly Central Falls and Pawtucket.

Most recently, they introduced the first mobile patient engagement app in Rhode Island that will allow patients to send their personally recorded health care data to their own electronic health records, achieving a meaningful use standard three years ahead of schedule. [See link to ConvergenceRI articles below.]

Instead of a one-size fits all system of health IT, the success of Blackstone Valley's integration of data at the point of care and patient engagement suggests that there is important value in solutions that reflect community needs and patient needs – and  not just large corporate system needs.

Population health analytics: mining the data
The holy grail of health care IT is the dream that software can be harnessed to improve the capability of health care systems to intervene in a more timely fashion: share health care data at the point of care, avoid unnecessary emergency room and urgent care visits and redundant tests, increase medication adherence, address chronic diseases in a more coordinated manner, and prevent unneeded hospitalizations.

Such aspirational goals are very much reflected in the grant application for the federal State Innovation Model funding, which Rhode Island intends to submit an application for by July 21, hoping to capture between $20 million and $40 million over the next four years to support the effort to transform Rhode Island’s health care delivery system.

In the plan for improving population health, the grant guidelines state: Rhode Island “must develop a statewide plan to improve population health.”

The plans should include integration of population health strategies with public health officials and health care delivery systems for all populations. At a minimum, the guidelines continue, “plans should address the core measures identified in the population health metrics document, namely: tobacco use, the incidence of obesity, and diabetes.”

In addition, the states are urged to consider strategies to integrate child wellness and prevention and address maternal depression to foster healthy child development.

Further, the characteristics associated with a transformed health care delivery system are:
• Providers across the state and across the care continuum participate in integrated or virtually integrated delivery models.
• More than 80 percent of payments to providers from all payers are in fee-for-service alternatives that link payment to value.
• Every resident of the state has a primary care provider that is accountable both for the quality and for the total cost of their health care.
• Care is coordinated across all providers and settings.
• There is a high-level of patient engagement and quantifiable results on patient experience.

Throughout the system, providers must leverage the use of health IT [emphasis added] to improve quality.

The limits of current data constructs
The proposed core measure of population health metrics to address tobacco use – and the need to leverage the use of health IT – provides some insight into the issue.

Over the last three decades, the aggressive public health campaign to halt indoor smoking in Rhode Island has resulted in demonstrative positive changes in population health.

Today, about 17.4 percent of Rhode Island adults still smoke, with similar rates for men and women and by race and ethnicity in 2012, according to the R.I. Department of Health.

The biggest differences in current smokers are reflected by income – adults who made less smoked more; education status – adults with a high school education or less smoked more [nearly 30 percent]; and by employment – adults who were unemployed smoked more [nearly 30 percent].

Equally important, in terms of health care access, smokers are more likely than non-smokers to be uninsured, have no primary care doctor, experience cost barriers seeing a doctor, and have not had a checkup in the past 12 months.

One of the benchmarks within the data sets of the R.I. Chronic Care Sustainability Initiative, or CSI-RI [and being rebranded as PCMH Rhode Island] are metrics about smoking cessation. Most of the participating primary care patient-centric medical homes are measured by monthly inquiries of patients.

The data from these practices is one of the key data sources being used by the Wakely Consulting Group’s total cost of care analysis for Rhode Island.

What’s apparently missing from the data – and from the cohort – are precisely those Rhode Islanders who are smoking the most: the uninsured [before health care reform, about 14 percent; now estimated to be about 7 percent]; those who don’t have a doctor, those with cost barriers preventing them from being able to see a doctor, and those without primary care who have not had a check up in the last year.

The costs of these adults to Rhode Island’s health care delivery system are real, even if they are not captured in the database – including Lifespan’s new $100 million Epic system.

A more troubling data point, according to a health official, is that as many as 50 percent of those adults with mental health and substance abuse problems in Rhode Island are estimated to be smokers – with smoking often serving as a crutch during recovery efforts.

The data captured on smoking cessation, it seems, depends on the ability to have insurance, have a primary care provider, and being able to afford to see a doctor.

To treat the person, and not the disease, may require a different approach and a different set of treatment and epidemiological data.