Photo: The only CEOs in Holston Medical Group’s 40-year history, Drs. Jerry Miller and Scott Fowler.
By Scott Robertson
Forty years ago, when Dr. Jerry Miller founded the practice that became the foundation of what is now Holston Medical Group (HMG), the healthcare landscape was far different than today. Back then, folks went to see their family doctor for check-ups. In some cases, the family doctor still made house calls. During check-ups, one might get advice from the family doctor on what one needed to do to stay out of the hospital. And if one wasn’t feeling well and was told by the family doctor to check into the hospital, that same doctor would be there too.
Over the last four decades though, specialization brought fragmentation to the healthcare industry. The primary care physician began handing a patient’s folder off to specialists at the hospital who would deal with whatever the specific problem might be.
Care improved as doctors who knew virtually everything about treating a specific problem set to work. But the more fragmented approach also helped create a disjointed, increasingly expensive system that has in the last few years hit a breaking point.
Re-establishing a seamless continuum of care through utilization of tools including information sharing and extensivist programs is key to what Holston Medical Group is doing today, says Dr. Scott Fowler, HMG’s president and CEO. “That’s the future,” Fowler says, “this sort of natural state.”
“We’ve spent a lot of time talking about what to do to move from this volume-based system that we have – this fragmented, siloed system where everybody is their own profit center with their own records – to the value-based system. But the value-based system is actually the natural state,” Fowler says. “The volume-based system was built up over time by putting various pieces on top of each other to create silos in different parts of the system. Some of what we’re doing is just removing the barriers to putting the patient back at the center rather than having different pieces be the centers of their own universes.
“The most basic pieces that have to be in place concern the coordination of care,” Fowler adds. “You don’t want to get rid of specialists; they do extremely important things. We know more about the heart than we used to know. There are things you have to be very skilled at and do over and over again to be really good at it. On the other hand, every person is a custom model. There is no common model. So the coordination of care, especially in complex disease where you have multiple diseases interacting with each other becomes actually more important than the specialization of medicine. I think that’s where we have gotten in trouble.”
Fowler admits the focus on coordination isn’t an absolute. HMG is a multi-specialty physicians group, after all. “When a patient has a single problem – a heart issue for instance, then going to a specialist who knows the heart literally inside and out is what one needs to do. Inter-provider coordination is far less important because one physician can simply say, “I got this.”
“But when you talk about most diseases, which don’t just affect a single organ,” Fowler says, “you really need a coordinated system. The coordination becomes more important than the specialization.”
That shift in focus has taken years, and continues to occur in, around, through, and sometimes despite whatever changes occur in the political back-and-forth over payment plan models. HMG had a unified electronic medical record 20 years ago. “Now it’s a much bigger picture because we work with a lot of specialists who aren’t in our system,” Fowler says. “Just having an electronic record inside HMG or a hospital or another group still fragments the data. So the most important thing we have done is to try to create that common record experience for a patient amongst all the doctors caring for them.”
That was the basis for the creation of the OnePartner Health Information Exchange (HIE). “We will continue to try to convince others to make the best use of the HIE, and to try to continue to make opportunities for that to be a possibility.”
Currently, Wellmont Health System and Mountain States Health Alliance are sending around 100,000 patient visit records a month to the OnePartner HIE for consumption by physicians in the community caring for the patients outside the walls of the hospitals. In total, across all communities the OnePartner HIE services (the Tri-Cities, Southeastern Nebraska, Southern New Hampshire) OnePartner receives approximately 420,000 patient visit records per month. In the Tri-Cities, around 1,500 physicians are participating.
“Anytime you try to do something new like that you have the barrier of change. That requires a lot of explanation. Secondly you always have a financial barrier where you figure out how to pay for it. So as we do this we have to create an environment where it’s pretty easy for everybody to connect no matter what the setting. We’re trying to form a system where everybody can stay in their optimized relationship with the patient, but still get the system where when the patient goes to the hospital, they’re not losing contact with the person who probably has the best relationship with the patient over time.”
In pointing out HMG’s history of innovation, Fowler also points forward, citing the extensivist program. “We think this is the solution for the community – to say, ‘Look, there are some patients who are not like others. They have more complicated disease.’ Our current system creates everybody like they’re the same. They’re not. They’re not all 1974 Toyota Corollas. They’re all custom models at different levels. We have to understand the differences if we are to apply resources in a cost-effective, value-based way.
“Forty years ago, the physician would know that this patient needs more attention than that one. The extensivist program provides additional resources for patients who need more time with a doctor or additional coordination of care. It’s basically taking our hospitalist to join the primary care doctor to a doctor in the hospital in a team relationship. That allows the patient, whether in or out of the hospital, to receive coordinated care. So the hospitalist is no longer just responsible for the patient within the walls of the hospital. Now we work around the patient, not the building. All the resources we would normally apply in primary care are still there, plus this additional outpatient relationship that hopefully will prevent patients from sitting in ERs for hours and getting admitted because nobody knows who they are and what medicines they’re on.”
While it might sound like the extensivist program merely adds one more layer to an already unsustainably complicated model, Fowler says the idea is that the extensivist will remove inefficiency from the system. “Most of the patients that hit the ER with complex disease get admitted. They don’t necessarily get admitted because they need to get admitted. They get admitted because there’s no place else to take care of them and they have complicated disease. So we had built a model that forces them into the ER. It turns out those are the most expensive, and in some cases less effective places to take care of chronic diseases.”
Fowler clarifies that he’s not talking about acute disease, heart attacks and other perfectly appropriate instances to visit a hospital emergency department, “but the old model forced us into inefficient patterns. In order to get back to a patient-centric model, it makes more sense to go to an outpatient clinic when you get into trouble with your multiple diseases, to see doctors who know exactly who you are.”
The HIE and the extensivist program are two ways HMG is trying to work within a changing system to continually improve efficiency, Fowler says. “The status quo is constantly changing. Change is both an opportunity and an inevitability.
“Personally, as HMG celebrates 40 years of service, I’m humbled by the honor of serving our patients and community as the President of Holston Medical Group,” Fowler concludes. “There is no higher calling than service and no better time for being a part of leadership than during times of change.”