ManagedCarePartners Winter 2018 A Johns Hopkins Medicine Publication for Managed Care Organizations

Telemedicine Increases Access, Adds Value

he Department of appointments with his patients who have Emergency Medicine at The amyotrophic lateral sclerosis (ALS); Johns had Hopkins pediatric cardiologists provide a problem: In the early hours echocardiography consults to patients at Sibley of the morning, between Memorial Hospital in Washington, D.C.; Tmidnight and 3 a.m., when fewer triage and patients presenting to Howard County personnel were available, as many as 25 General Hospital’s emergency department percent of patients got tired of waiting and with eye problems are sometimes screened by left before being seen. ophthalmologists at the Wilmer Eye Institute But telemedicine helped provide a solution, rather than be automatically transferred to says assistant administrator Gai Cole. The Johns Hopkins Hospital’s emergency To save the expense of hiring additional department. staff, the department invested in telemedicine More than 20 additional telemedicine equipment. Since April, patients with less projects are planned for the next year, urgent needs have been taken by a certified Canino says, including a video visit offering nursing assistant to an exam room that has a that will allow patients to meet with several telemedicine cart. Using a handheld camera, specialty physicians at the same time, making the certified nursing assistant zooms in on coordination of treatment possible. wounds and peers into eyes, ears and throats, The telemedicine office is also looking to while a physician, via video conference, incorporate the registration and copayment interacts with the patient and forms a process within MyChart so patients can treatment plan. More than 6,400 patients have check in from home. Documentation for been evaluated this way since the program telemedicine visits, like that for in-person started, says Cole — it’s been so successful visits, is done through Epic, the electronic that within four months of its use, the walk- medical record. out rate plummeted to 4.5 percent. Telemedicine appointments not only save Expansion to Johns Hopkins Bayview patients the time and travel costs associated Medical Center and Howard County with in-person visits, Canino says, but are also General Hospital is an option. more likely to start and end on time. Overall, It’s just one example of active telemedicine patients and physicians like them, adds projects occurring across Johns Hopkins ophthalmologist Ingrid Zimmer-Galler, Medicine, says Rebecca Canino, executive clinical director of the Office of administrative director for the recently Telemedicine. She says, “We use the internet created Office of Telemedicine. In other to order our coffee, say hello to our friends areas, neurologist Nicholas Maragakis and hold meetings, so why not see your uses telemedicine to conduct follow-up physician online?” n

MONTH 1

BEFORE THE EMERGENCY DEPARTMENT STARTED USING TELEMEDICINE IN TRIAGE, AS IT DOES NOW, AS MANY AS 25 PERCENT OF PATIENTS GOT MONTH 4 TIRED OF WAITING AND LEFT BEFORE BEING SEEN. NOW THE WALKOUT RATE HAS PLUMMETED TO 4.5 PERCENT. From the Office of Managed Care IDEAS AT WORK

Patricia Brown President, Johns Hopkins HealthCare

Big-Picture Innovations Bring Better Care

In a traditional fee-for-service model, one wouldn’t necessarily expect an academic medical center such as The Johns Hopkins Hospital to closely collaborate on patient care with competi- tors like Mercy Medical Center or Sinai Hospital. Yet that’s exactly what’s happening through the Community Health Partnership of . This regional partnership, like similar ones in Howard County and Montgomery County that Johns Hopkins Medicine is participating in, focuses on engaging people at high risk for hospital use, particularly those who are chronically ill and do Integrating to Create Value not have a medical home where they receive high-quality health care. In other words: They are The Johns Hopkins Hospital and Johns Hopkins Bayview Medical falling through the cracks. What works in Howard Center are working closer than ever to deliver the high-value care that County may differ from what works in Baltimore City, but we’re learning from each other and health system patients deserve. bringing our best innovations and practices to the table to help individuals receive coordinated care ying three miles apart, The Johns for patients,” says Miller. To that end, all patients through health navigators, in-home services and Hopkins Hospital and Johns Hopkins receiving solid-organ transplants, eye surgeries links to community resources. Bayview Medical Center have long or cardiac electrophysiology procedures are now These partnerships highlight the importance worked together to deliver high-value treated at The Johns Hopkins Hospital, while those of managing innovation so that it proceeds care. For instance, Johns Hopkins in need of a sleep disorders specialist, bariatric efficiently. Take our cover story on telemedicine. LBayview once hosted the state’s only regional burn surgery, total joint replacement, or medical and The technology had been springing up in several center. But nearly a decade ago, says the medical radiation treatment for new lung cancers are seen at areas around Johns Hopkins Medicine on an ad hoc center’s president, Richard Bennett, leaders at Johns Hopkins Bayview. basis, with interested physicians trying to figure Johns Hopkins Medicine realized that children In areas where there is a large demand for it out independently. Now, a newly established with burns would benefit from the pediatric Johns Hopkins expertise, such as neurosurgery, Office of Telemedicine helps physicians turn their intensive care unit and surgical expertise found at obstetrics and neonatal intensive care, services ideas of how to use telemedicine into reality in the Johns Hopkins Children’s Center, part of The are offered at both hospitals but function as one an organized fashion: Pilot projects are organized Johns Hopkins Hospital in East Baltimore. Thus larger unit, adds Bennett. a pediatric burn unit was established there, and Integrating pharmacy services across the two and start small. Once a good model is reached, Johns Hopkins Bayview focused on adults. hospitals has generated efficiencies and savings. functionality is built into our electronic medical “I think the market demand for value is higher Looking for such opportunities to combine services record system so more health care professionals than ever,” says Redonda Miller, president of The is a goal of the academic division operating group, can participate. Johns Hopkins Hospital. With health care costs which is composed of leaders from both hospitals. Of course, innovation requires leaders who can at 18 percent of the ’ gross domestic Other joint efforts include a value analysis team that see the big picture. For us, that involves serious product, she says, “There’s simply no more money to standardizes purchases for both hospitals’ operating integration efforts. In “Meet Your Partners,” infuse into health care. We have to be smarter and rooms and a high-value care committee working to you’ll read about Peter Hill, who has taken on use the dollars we do have more wisely.” reduce unnecessary testing and variations in care. the dual role of managing medical affairs for The In many cases, says Miller, it’s not in patients’ And last year, Charles Reuland was named Johns Hopkins Hospital and for the Johns Hopkins best interest to have two smaller programs on executive vice president and chief operating officer Health System. This means he is not only working two campuses. “We know from medical literature of both hospitals to oversee additional integration in East Baltimore to lead the medical staff and that the more we specialize and concentrate our efforts. “We approach integration from this services within one team, the more expert the perspective: Does it add value? We don’t do it just provide direction for patient safety programs and team becomes, which produces better outcomes because it’s good to say you did it,” says Reuland. n pharmacy services, but he’s also working with clinical directors systemwide to improve quality and efficiency. Likewise, Redonda Miller, president of The Johns Hospital, and Rick Bennett, president of Johns Hopkins Bayview Medical Center, are “THERE’S SIMPLY NO MORE MONEY TO INFUSE INTO continuing a longstanding tradition of consolidating HEALTH CARE. WE HAVE TO BE SMARTER AND USE expertise in specialty areas on one or the other THE DOLLARS WE DO HAVE MORE WISELY.” campus to function together as one larger unit. —REDONDA MILLER, PRESIDENT, THE By keeping open to innovation and working JOHNS HOPKINS HOSPITAL together, we are able to deliver better value to Johns Hopkins patients and payers. n MEET YOUR PARTNERS

Peter Hill Becomes Senior Vice President of Medical Affairs for Johns Hopkins Health System

olcanoes were Peter Hill’s Hill also initial passion, but after meeting coordinates and marrying his wife, a hospital weekly calls with administrator, he decided to pursue other health work that was more connected to system leaders to Vothers’ lives and become a physician. Hill left his cover system- “WHAT GETS ME EXCITED IS THE volcanology program with a master’s degree and level issues such OPPORTUNITY TO BRING PEOPLE attended the University of School of as multihospital TOGETHER FROM DIVERSE BACKGROUNDS AND DISCIPLINES TO SOLVE PROBLEMS.” Medicine. After a residency at Johns Hopkins in credentialing emergency medicine, Hill joined the faculty as for clinicians —PETER HILL, SENIOR VICE PRESIDENT OF MEDICAL assistant chief of service. who work in more AFFAIRS FOR JOHNS HOPKINS HEALTH SYSTEM Today his work considers burning issues of than one Johns another sort. As senior vice president of medical Hopkins setting, and affairs for the Johns Hopkins Health System and he works with pharmacy operations, service delivery, risk management and vice president of medical affairs for The Johns services to identify opportunities to reduce quality improvement. Under his leadership, the Hopkins Hospital, positions he was promoted to medication costs. He’s also part of the Joy of department saw increased diagnostic accuracy for in March, Hill is helping the health system address Medicine task force, which is looking for ways to patients and reductions in unnecessary hospital the opioid crisis. To that end, he and colleagues at help everyone ease a challenging job. admissions. n Johns Hopkins, the University of Maryland and “What gets me excited is the opportunity to MedStar Health collaborated to make changes bring people together from diverse backgrounds to the Maryland Medicaid opioid prescribing and disciplines to solve problems,” Hill says. initiatives, undertaken July 1. In addition, he has Before taking on his current role, Hill served spent time establishing an opioid stewardship as vice chair of clinical affairs for the Department clinical community to shape the health system’s of Emergency Medicine. In that position, which use of opioids for pain management. he started in 2012, Hill took particular interest in

IDEAS AT WORK

of help offering home care visits, Johns Hopkins Medicine accompanying patients to primary or specialty care appointments, and Hospitals Join Regional connecting patients to resources for any socioeconomic needs. Other Partnerships to Improve initiatives smooth transitions to home or a postacute care unit, offer disease Population Health management classes and caregiver help, and supply rapid access to behavioral hen Maryland’s partnerships aim to connect health care. More than 500 people Health Services patients who have three or more have been touched by this partnership Cost Review hospital admissions to a regular since it started in July 2016. Commission health care provider, work out A third partnership, based in put out a call treatment plans and help with Linda Dunbar, vice president of Montgomery County, includes population health for Johns Hopkins , along with forW regional partnerships to improve social determinants of health, such HealthCare. population health and decrease as barriers to transportation and five non-Johns Hopkins Medicine hospital readmissions among high-user healthy food, or finding affordable and a bridge to community-based medical centers. The Nexus Medicare recipients, Johns Hopkins housing, Dunbar says. mental health services. Montgomery Regional Partnership’s Medicine jumped at the opportunity. Community Health Partnership “Some of the individuals we contact programs include WISH (Wellness Now, four of the health system’s is coordinated by Johns Hopkins have as many as six or seven chronic and Independence for Seniors hospitals are active in three of eight HealthCare and comprises The Johns comorbid conditions, mental health at Home), which provides case statewide partnerships working to Hopkins Hospital and Johns Hopkins diagnoses and substance use diagnoses, management to some 7,000 seniors provide better care to these patients. Bayview Medical Center, as well as so it’s a very complex picture that we’re in 42 independent-living facilities They are the Community Health Sinai Hospital, Mercy Medical Center seeing,” says Dunbar. found to have high hospital use. Partnership in Baltimore, Howard and two MedStar hospitals. Working Leaders at Howard County General Other efforts furnish funds for a Health Partnership and Nexus with community health partners, Hospital study their inpatient list every crisis house for patients with severe Montgomery Regional Partnership. Community Health Partnership serves morning, looking for eligible adults mental illness and help get uninsured “What we’re finding is these residents in 19 ZIP codes surrounding for the Howard Health Partnership, patients access to specialty care. patients are not well-connected East Baltimore, with about 200 of a says Elizabeth Edsall Kromm, The best part, says Margie to a medical home, so many of planned 1,300 patients enrolled. Its vice president of population health Hackett, a transition guide nurse them are using the emergency network of community care teams and advancement. They want to manager at Suburban, is how the department and the hospital as and workers reaches out to patients for make patients feel like they’re active partnership allows better care their primary source of care,” says initial health assessments and creates participants in their health care, says coordination for patients who might Linda Dunbar, vice president care plans. Additional efforts are Edsall Kromm. be seen at multiple facilities: “This of population health for Johns medical visits for homebound seniors, A multidisciplinary community care collaboration between facilities is like n Hopkins HealthCare. So the transitional housing for the homeless team provides one to three months none other.” BITS, BYTES & BRIEFS HOPKINS IN THE NEWS

Unneeded Medical Care Is Eliminating a Widely Used—and Johns Hopkins Health System Common Unnecessary—Blood Test Reduces Unnecessary Transfusions A national survey of more than 2,000 Based on five peer-reviewed studies, A blood management program launched five physicians finds that they believe researchers at the Johns Hopkins University years ago has reduced unnecessary and potentially dangerous transfusions in the Johns Hopkins Health overtreatment is common, mostly School of Medicine and the Mayo Clinic System, leading to improved care and annual cost perpetuated by fear of malpractice, though have created guidelines to help physicians savings of more than $2 million, according to a patient demand and profit motive are factors, and medical centers stop the use of a study published Sept. 7 in the Online First edition too. A report on the findings was published widely ordered blood test, creatine kinase- of Anesthesiology, a peer-reviewed journal. The Sept. 6 in PLOS ONE. “Unnecessary myocardial band (CK-MB) testing, because program’s educational outreach consisted of live, medical care is a leading driver of the higher it adds no value in evaluating patients with in-person Grand Rounds presentations to clinical health insurance premiums, affecting every suspected heart attack. The report, published departments to inform physicians, nurses and Martin Makary others about transfusion policy guidelines and American,” says , professor Aug. 14 in JAMA Internal Medicine, the results of eight landmark studies that support of surgery at the Johns Hopkins University is the first in a series of peer-reviewed reduced use of transfusions. School of Medicine and the paper’s senior implementation guides coauthored by faculty author. Unwarranted medical services members from the High Value Practice “Doctors don’t want to be told how to practice represent the majority of wasted health Academic Alliance (HVPAA), a national medicine by computer pop-up alerts—they care resources in the U.S., accounting for coalition created by the Johns Hopkins would rather hear about the studies supporting about $210 billion in excess spending a University School of Medicine. Faculty the guidelines,” says Steve Frank, professor of anesthesiology and critical care medicine at the year, according to the National Academy of members from more than 80 academic Johns Hopkins University School of Medicine and Medicine. Studies show that overtreatment institutions have joined HVPAA to advance the paper’s first author. Frank is now working with is directly associated with preventable value in medicine. NYU Langone Health and the Cleveland Clinic on a patient harm. On a national scale, the issue publication to educate other health systems about represents a significant opportunity to transfusion use. improve patient safety and lower health care costs, says Makary.

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Managed Care Partners is published three times a year by Johns Hopkins HealthCare LLC. For more information, call 410-614-3227, or write to Patricia Brown, president, at the above address. Produced by Johns Hopkins Medicine Marketing and Communications: 901 S. Bond St., Suite 550 Baltimore, MD 21231 Dalal Haldeman, Ph.D., M.B.A., senior vice president Christina DuVernay, Ph.D., managing editor Karen Blum, Christina DuVernay, writers Lori Kirkpatrick, designer Keith Weller, photographer ManagedCarePartnersWinter 2018 A Johns Hopkins Medicine Publication for Managed Care Organizations

1 2 3 Telemedicine Integrating to Peter Hill Increases Create Value Becomes Senior Access, Adds Vice President of Value Medical Affairs Inside MCP