Atlanta-based Emory Healthcare is looking to scale up its population health management efforts, expanding primary care to hundreds of thousands of patients across Georgia, and tapped health tech company Guidehealth to turbocharge its work.
The academic health system, along with its clinically integrated network called the Emory Healthcare Network, is teaming up with Guidehealth to launch a new population health collaborative to expand value-based care to more than 350,000 patients.
The new entity integrates Emory’s growing primary care service line and affiliate physician network. The goal of the collaborative is to accelerate performance of quality of care and overall health outcomes across Emory's primary care clinics and network, executives said.
Emory Healthcare includes more than 490 provider locations with 10 hospitals and comprises the Emory Physician Group and the Emory Healthcare Network, a clinically integrated network with more than 4,000 physicians including more than 500 primary care physicians.
The academic health system has been involved at a smaller scale in population health management for a number of years as it was developing its clinically integrated network, said Patrick Hammond, CEO of the Emory Healthcare Network who was also tapped to be the CEO of the Emory Healthcare Population Health Collaborative.
"As the Emory Healthcare Network has now grow from a network of about 145 primary care physicians to now over 500 primary care physicians, and from zero attributed lives to over 345,000 attributed lives, Emory Healthcare made the strategic decision that it was time to make a significant strategic investment to take Emory Healthcare’s population management efforts to a higher level of scale and performance," Hammond told Fierce Healthcare.
As part of this initiative, more than 500 Emory primary care and affiliate primary care providers will offer patient care, education, research and community engagement in their clinic locations. Providers, who will aim to see patients at least once a year, will assess patient health needs and determine their outlying risks to prevent problems and get ahead of diseases before they develop and advance.
While at appointments, patients may have lab work and other screenings performed to look for chronic disease states—such as diabetes, high blood pressure and high cholesterol—early in the process before patients need treatment.
"This collaboration focuses on increasing the frequency and effectiveness of preventive visits, screenings and improving patient engagement, all while reducing the administrative and operational burden on our healthcare providers so they can focus more on what they do best: helping their patients and serving our communities," Hammond said. "How we will measure the success of this initiative is rapidly moving to 4 Star or higher quality performance and bending health care cost trends."
As a new player, Guidehealth, which launched just last year, has big ambitions to help providers succeed in value-based care models and improve their performance in risk-based contracts. The startup uses advanced technology to support health systems and clinical networks in scaling value-based care beyond the inpatient setting. Guidehealth facilitates care coordination like prior authorization and referrals and uses artificial intelligence to better predict the needs of patients. Guidehealth also assigns virtual clinical team members to work with its partner systems, called Healthguides.
"We provide predictive analytics, profiling and building unified care plans for patients. We also provide AI-assisted staff, our Healthguides, to improve quality, clinical documentation and care management," Guidehealth founder and CEO Sanjay Doddamani told Fierce Healthcare. "Guidehealth also uses targeted and safe AI agents to further extend our team and improve patient engagement and convenience. Collectively, Guidehealth is a proven partner for health systems with seasoned value-based care leaders who know how to get results."
Emory evaluated a number of potential value-based care organizations, Hammond noted. Guidehealth checked off a number of boxes that Emory was evaluating in the selection of a strategic relationship, including its ability to integrate its capabilities into the health system's clinical workflows.
Partnering with the company provides Emory with the ability to rapidly accelerate its performance in value-based agreements while lowering ramp-up scaling costs, he noted. The partnership also lowers the operational execution risk cost to Emory, and Guidehealth provides a solution for all payer classes, such as Medicare and commercial insurance.
The partnership also enables Emory to collaborate with a hybrid solution where the academic medical center continues to build some of its own population management internal capabilities as well leverage tools and resources Guidehealth could bring to the team. Further, it accelerates Emory’s ability to take on two-sided risk, especially in Medicare, Hammond said.
"Guidehealth brings not only an industry-leading population management and analytics platform, it also has been developed to support workflows in clinical practices. Additionally, Guidehealth better enables different primary care offices working with different electronic medical records to be successful in population management without significant changes to their standard workflows today," he said.
Back in December, Guidehealth bought Arcadia's managed service organization and value-based care service division to build out its tools and services for providers.
In August, the company picked up a $14 million seed round backed by nonprofit Memorial Hermann Health System, entrepreneur Sidd Pagidipati and other healthcare investors and industry leaders.
Emory Healthcare currently has advanced and robust data and analytics capabilities, noted Alistair Erskine, M.D., Emory Healthcare chief digital and information officer. But, to deliver value-based care results across a network of Emory's size, the health system must continue to combine timely and actionable data with better predictive models, he said. "We look forward to working with Guidehealth and its ecosystem of advanced analytics and AI collaborators to leverage the infrastructure to better serve our patients, especially those with complex or unmet needs," Erskine said.
Primary care physicians also are under stress from growing administrative burdens and time-consuming paperwork done through electronic health record systems. At the same time, the U.S. faces a critical shortage of primary care physicians, with the labor crunch projected to get worse by 2036. Access to primary care doctors remains a barrier for many patients.
Emory's population health collaborative will support primary care physicians, such as alleviating some of the time-consuming administrative tasks. Guidehealth will virtually embed its clinical teams, including its Healthguides, within the primary care physician’s clinical teams to assist with patient coordination, data management and follow-up. Guidehealth's predictive modeling capabilities help providers pinpoint patients most likely to experience worsening health due to unmanaged conditions. Physicians can track health patterns and intervene early, helping prevent complications and hospitalizations.
The collaborative also will help providers more effectively shift to value-based care by embedding quality and performance metrics directly into their workflows, helping them align daily practices with broader value-based goals, executives said.
Doddamani also pointed out that Guidehealth's Healthguides work within the primary care practice and a health system's EHR and are designed to engage with patients, helping them follow their care plans. "With these personal relationships at the center, we can effect change in a myriad of ways: we can help resolve care access issues, find transportation, coach patients on how to take their medication, and elicit documentation needed to close care gaps," he said.
Both Emory and Guidehealth leaders are currently working with practices across the system and network to implement this new model and deploy the platform capabilities.