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Health IT Success Stories

Lone Star Circle of Care Leverages Health IT to Support an Accountable Care Organization

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Sarah Churchill Llamas is Chief Operating Officer of Health IT at Lone Star Circle of Care (Lone Star), a federally qualified health center (FQHC) in central Texas. Lone Star employs over 120 providers and serves more than 110,000 patients, many of whom are uninsured. At the heart of Lone Star is a robust electronic health record (EHR) system, which offers providers instantaneous access to patient data – including data from the community health information exchange (HIE) – as well as the Member Navigation Center, which is a centralized member navigation center staffed by patient service representatives, care managers, clinical interventionists, and referral specialists who are responsible for patient outreach and care coordination. Both the EHR system and the Member Navigation Center have been critical to Lone Star’s success with the Centers for Medicare & Medicaid Services Accountable Care Organization (ACO) model.

Meaningful Use: A Springboard for Practice Transformation

Achieving Stage 1 meaningful use helped Lone Star fine tune its health care quality improvement processes and ultimately prepared the organization for future quality improvement initiatives. “Meaningful use accelerated our long-standing focus on analytics as the driver of better patient outcomes,” explained Dr. Tracy Angelocci, Chief Medical Information Officer at Lone Star. Lone Star began using web-based quality reports drawing data from its EHR system, for example, so that providers could track their progress on clinical quality measures (CQMs). “The quality reports, which pull patient data from the EHR system, are updated daily and show performance on CQMs on the organizational, provider, and patient-level,” said Ms. Churchill Llamas.

When Lone Star began participating in the ACO, Ms. Churchill Llamas knew that Lone Star’s work on meaningful use would come in handy. “When we joined the ACO, we realized that much of what we are required to do is a lot like meaningful use,” explained Ms. Churchill Llamas. “Organizations that participate in an ACO must measure and meet 33 quality performance standards in order to share in savings.” Having already achieved meaningful use, Ms. Churchill Llamas knew Lone Star could leverage its web-based clinical quality measure reports to improve its performance on the ACO measures.

Member Navigation Center Helps Coordinate Care for ACO Patients

Lone Star’s Member Navigation Center, which is Lone Star’s control center for patient outreach and follow-up, is charged with coordinating care for Lone Star’s patients, including the ACO patient population. Using the EHR system’s web-based quality reports, the Center’s care managers are able to track Lone Star’s progress against the ACO measures and identify areas for improvement. If a quality report indicates Lone Star is meeting a diabetes performance measure in only 50% of visits, for instance, care managers can use web-based quality reports – which serve as “care-gap analyses” for patients with diabetes – to determine what Lone Star can do to improve its performance. “Based on the quality reports, care managers can proactively address care gaps,” explained Ms. Churchill Llamas. “If one of our patients with diabetes is due for a blood-sugar level check, a care manager will see it on the report and call the patient to schedule an appointment.” Using data from the web-based quality reports, care managers at the Member Navigation Center are identifying and eliminating critical gaps in patient care.

Current Success and Continued Health IT-Driven Quality Improvement

Since joining the ACO in 2012, Lone Star has seen significant improvements in health care quality. Lone Star increased breast cancer screening by 48% and colorectal cancer screening by 71%. Furthermore, after becoming a patient at Lone Star, patients are four times less likely to have an emergency department visit. “Our EHR and local HIE systems enable our organization to support and care for patients between office visits, not just when they come into the clinic,” said Ms. Churchill Llamas. “With Health IT, our goal is use data to help our patients live healthy lives.”

Lone Star continues to find new ways to leverage Health IT for health care quality improvement. “We use information from the local HIE for our care management efforts,” explained Ms. Churchill Llamas. “We use the data to identify patients presenting at the emergency department and contact them within 48 hours.” Lone Star also uses a community-wide longitudinal patient record to get a robust picture of each of their patients, which helps Lone Star’s providers and staff have relevant and respectful conversations with patients. To increase patient engagement, Lone Star is also in the process of developing its own patient portal. When the patient portal is rolled out next year, it will have multilingual capabilities and support mobile technology so that patients can access their health information on their smartphones in several different languages. “The patient portal is an exciting opportunity to engage our patients like never before,” said Ms. Churchill Llamas. “With more information, our patients can take ownership of their health care.”