As the healthcare industry transitions to value-based care, urgent care companies and health systems are forging formal business partnerships and then facilitating those relationships through the exchange of electronic patient data.
The partnerships have advantages for both parties. Health systems want to add urgent care to their patient care continuum, while urgent care companies want to be included in local provider networks.
As patient care is increasingly provided under risk-based contracts, urgent care centers that are not part of provider networks will “lose more and more patients because the patients are going to go places that are in their network,” explains Tom Charland, founder and CEO of Merchant Medicine, a consulting and research firm based in Shoreview, Minn.
Therefore, urgent care companies “are afraid that with population health, they could be left on the outside looking in and have no participation,” says Charland, whose firm specializes in urgent care and retail medicine.
Meanwhile, health systems want access to the patients who visit urgent care centers, particularly those who do not have an ongoing relationship with a primary care physician. “They have to have scale to have success in population health,” Charland says.
Urgent care is an important piece of the patient-care continuum because the model facilitates quick, inexpensive and convenient medical care for patients. The centers are often built in local neighborhoods, open long hours every day, and treat a wide range of medical issues with minimal waiting.
“We refer to it as the front door to the health system. It’s an opportunity to get patients into the system, and then we direct patients into the right settings from there,” says Steve Sellars, CEO of Premier Health, an urgent care company based in Baton Rouge, La. Sellars also is president of the Urgent Care Association of America (UCAOA).
As a result of this role in the patient-care continuum, the urgent care industry has grown by about 600 centers per year since 2011, according to the UCAOA, which estimates that there were 7,100 urgent care centers in the United States as of 2016.
The centers are divided equally among three ownership types, according to Charland—independent urgent care companies that own numerous centers and often in multiple cities and states; centers owned by hospitals or health systems; and centers owned by local physicians or business people.
But when health systems decide not to develop the centers themselves, they often create formal business arrangements with independent urgent care companies, according to Charland.
For example, GoHealth Urgent Care, based in Atlanta, has 37 urgent care centers in the New York and Portland, Ore./Vancouver, Wash., metropolitan areas. It opened its first location in San Francisco in August 2016.
Launched in 2012, GoHealth develops a joint venture partnership with a health system in each local market, such as Northwell Health (formerly North Shore-LIJ Health System) in New York, Legacy Health in Portland, and Dignity Health (formerly Catholic Healthcare West) in the San Francisco Bay Area. The centers are co-branded to take advantage of the health systems’ “long-standing reputations in their market” and clinical expertise, explains Dev Ashish, senior vice president of infrastructure at GoHealth Urgent Care.
American Family Care, which has opened 160 locations in 26 states since 1982, traditionally developed corporately owned centers or licensed franchises to local business people and physicians.
More recently, it has been working directly with health systems. For example, it developed a franchise arrangement in Greenville, S.C., with Bon Secours Health System that includes four urgent care centers co-branded as AFC Urgent Care Bon Secours. It also has eight co-branded urgent care centers, called AFC-PriMed, through a joint venture with Baptist Health in Montgomery, Ala.
For any of these arrangements to succeed, however, the partners must develop and then execute a plan to exchange electronic patient information seamlessly. “The ultimate goal is to have overall better and improved coordination of care and reduction of fragmentation,” Sellars says.
Nearly all urgent care operators have an electronic health records system, according to Sellars, including those built specifically for urgent care, such as DocuTAP or Practice Velocity; those built for ambulatory settings, such as eClinicalWorks; or large, general systems, such as Epic or Cerner.
But data sharing is, by and large, in its infancy. “What we are seeing is a lot of activity around integrating electronic medical records, so that the primary care physicians are aware when one of their patients went to an urgent care center. It’s not, by any means, a completely done deal where everybody is integrated and there Is all of this integration at the API level—nowhere close—but there are clear indications that, I think, in the next three years it’s going to be a whole new ball game,” Charland says.
A case in point is GoHealth Urgent Care, which tailors its data exchange strategy to the local market.
For example, in Portland, GoHealth’s urgent care centers use that same Epic EHR as Legacy Health. “It is one patient, one chart. Whether a patient goes to a Legacy facility or a GoHealth facility, it is the same database in Epic, and it is the same patient chart in Epic that is being accessed by different providers in different places,” Ashish says.
In New York and California, GoHealth clinics use eClinicalWorks’ EHR product. GoHealth shares bi-directional electronic patient data with Northwell’s corporate Health Information Exchange, or HIE, using HL7 messaging. It is working on a similar strategy to share data with Dignity Health.
“When a patient walks into a facility, we look them up first in the Northwell HIE. Given Northwell’s huge footprint, we are making the assumption that the patient is part of the Northwell family,” Ashish says. If the patient is in Northwell’s HIE, the patient’s demographic, insurance and clinical information is fed to eClinicalWorks, which creates a medical record for the patient. After the visit, a continuity of care document (an electronic record that includes clinical, administrative and demographic data elements for a specific patient visit) and the clinical notes are fed back to Northwell’s HIE.
To create and manage the HL7 data exchange, GoHealth uses Orion Health’s Rhapsody Integration Engine. GoHealth bought the Orion Health product after “one of these interfaces—one of these pipes—essentially broke in the middle, and nobody was the wiser for it. We found out was that no information had been exchanged (for) four hours. That is not acceptable to either one of us,” Ashish says. “What we found out pretty quickly is there needs to be some level of visibility into these messages,” he says.
American Family Care also is working on exchanging patient data with its health system partners. It’s currently in the midst of a pilot test to exchange patient data between the AFC-PriMed urgent care centers in Montgomery, Ala., which use DocuTAP’s EHR, and Baptist’s HIE.
“The vision is that there would be just another tab within our EMR. Once you click on that tab, the tab actually shows certain information,” says Anthony Williams, CIO at American Family Care. For example, “we want to know when our patients have been to the hospital, what they were seen for, and what those outcomes were,” he says.
Premier Health also is using HL7 messaging to exchange patient information with Indiana University Health, based in Indianapolis. Currently, five urgent care centers, which use DocuTAP, are included in a joint venture arrangement between Premier and Indiana University Health, which uses Cerner.
Premier Health is in the midst of developing a similar integration in Baton Rouge, La., where it operates urgent care centers under four separate joint ventures. Premier has created a separate joint venture with each of four physicians groups that are part of Franciscan Missionaries Our Lady of the Lake Health System. At Our Lady of the Lake, the four physicians groups are on Epic, while its hospitals are on Cerner.
In Indiana, where data exchange has been live for about six months, Premier Health sends a continuity of care document to its partner’s EHR, but Premier Health does not store clinical information originating from Indiana University Health in DocuTAP.
In a separate joint venture with LSU Health Baton Rouge, a division of Our Lady of the Lake, two urgent care centers share an version of Epic’s EHR with LSU. That same type of data sharing arrangement is in place in Birmingham, Ala., where Premier Health has a joint venture in place with St. Vincent’s Health System. In that case, one urgent care center is on the same EHR—athenahealth—as St. Vincent’s Health System.
At Premier Health, American Family Care, GoHealth and other urgent care operators, integration efforts with other providers can be hampered by numerous challenges.
First, it’s expensive. “When it comes to interoperability and data exchange, you're really looking at having dedicated resources,” including software, such as an integration engine, and personnel, Williams says.
Another type of expense is the integration fee paid to EHR vendors. At Premier Health, these integration fees add up quickly because each joint venture has a separate database. “There is a fee for every integration—every database,” Myrtha Nobles, director of support services, says.
There are technical challenges, too. Setting up real-time communications can be tricky, Ashish says. When GoHealth’s registration clerks query Northwell’s HIE, they need a quick response because the patient wants to complete the registration process quickly.
“When we are waiting for the demographic information from their system, we are waiting in real time. We had to figure out how to cut down on some of the lags and ensure that performance is excellent,” Ashish says.
Translation also can be challenging. When they were developing the GoHealth and Northwell integration in November 2014, for example, Northwell was using ICD-10 codes while GoHealth was using ICD-9 codes.
With all of the hurdles GoHealth faced in its integration project with Northwell, Ashish says the “secret sauce” was partners who invested time and money in the project. “We had two sides that were committed to the cause,” Ashish says.
Data exchange efforts between health systems and independent urgent care companies will become increasingly important—separating winners and losers—as independent urgent care chains seek to become involved in performance-based reimbursement contracts with other healthcare providers.
That certainly is the ultimate vision for many urgent care chains. As a hypothetical example, Sellars points to global reimbursement contracts for a defined episode of care, such as a total joint replacement.
If patients are worried about whether their healing process is on track, but they can’t reach their physician, “they can go to the urgent center to make sure it’s not something that warrants going back to the hospital. Urgent care can play the important role of helping to prevent readmission in a bundled payment scenario,” Sellars says.
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