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Delivery of Care

Creating a full service orthopedic delivery system in RI

Ortho Rhode Island, the largest orthopedic group practice in the state, moves ahead with its new facility in Warwick, putting the focus on innovation, access, and paying attention to what patients want

Photo by Richard Asinof

Mary Ellen Ashe, the executive director of Ortho Rhode Island, the largest orthopedic group practice in Rhode Island.

By Richard Asinof
Posted 12/3/18
The emergence of Ortho Rhode Island as the largest orthopedic group practice in the state, with its emphasis on thinking like a patient, represents the creation of a full-service orthopedic delivery system. With the approval of its new facility in Warwick, the private, physician-led group practice is poised to challenge the future dimensions of health care delivery.
How will patients owning their own health data and determining how it is shared change health care delivery? How much of the emphasis with the new model of health care delivery planned by CVS, following its $70 billion takeover of Aetna, and the focus on chronic diseases, will be to invest in prevention and place-based health? What will be the response from journalists if they discover that their health plans no longer cover pregnancy and childbirth expenses, because it is a pre-existing condition? What is the current projected growth in demand for knee and hip replacements in Rhode Island? What are the lessons to be learned by the Care Transformation Collaborative on how Ortho Rhode Island is building a database on patient-reported outcomes?
The latest reports by the R.I. Department of Education on the results of the standardized testing for students has produced much gnashing of teeth and hand-wringing about what is wrong with our educational system and with our teachers. What hasn’t become part of the conversation, and should be, is this: what is the connection between poor educational outcomes and health, economic and social disparities? How would the creation of a place-based health equity system change the current educational outcomes around things such as chronic absenteeism?
Instead of trying to pin the blame on our educational system and on our teachers and parents, maybe it requires more state investment in access to affordable health care, access to safe, affordable housing; and access to affordable childcare.
More than that, it requires a recognition that as good as Rhode Island performs in testing children for lead poisoning and requiring better enforcement of building codes, the research has demonstrated that lead poisoning persists in children, teenagers and adults, causing declines in performance in standardized reading and math tests.
Recent studies have also pointed the critical importance in breast-feeding in creating epigenetic changes that provide young infants’ brains to resist toxic stress and anxiety.

WARWICK – Next week, on Wednesday, Dec. 12, the Planning Board is expected to give its final approval for the new biomedical office and ambulatory surgery center that will serve as the new headquarters for Ortho Rhode Island, the largest orthopedic group practice in Rhode Island.

The new facility, for which land clearing is expected to begin in January of 2019, will be built on a six-acre parcel adjacent to the Crowne Plaza, developed in partnership with the Carpionato Group.

At the initial announcement of the new facility in August of this year, Dr. Michael P. Bradley, president and CEO of Ortho Rhode Island, spoke about how the new facility fit into the vision for the private group practice.

“Ortho Rhode Island’s vision is to offer patients high-quality, high-touch care,” Bradley said, as reported by The Providence Business News. “With this center, we will be able to provide those values in a highly innovative, high-tech, world-class facility.”

The story of how Ortho Rhode Island came to be is one that exemplifies the power of serendipity and collision in the innovation ecosystem: five colleagues from Rhode Island met up at an orthopedic conference, all worked for competing specialist practices; all were friends, having trained together at the Warren Alpert Medical School; all were frustrated by the current system of health care delivery.

Over a cup of coffee, the five sketched out on napkins the idea for a new group orthopedics practice, based on answering the question: what if the new practice was designed to “think like a patient.”

The new group practice, Ortho Rhode Island, was launched in May of 2015, with the goal of redesigning the delivery of orthopedic care from the patients’ perceptions of their experiences. [See link below to ConvergenceRI story, “Living in an accountable world: orthopedic focus puts focus on patients.”]

Now, three and a half years later, Ortho Rhode Island is poised to take its next big step forward: consolidating its network of 17 offices in a central headquarters in Warwick, with the goal of creating a new way of delivering orthopedic health care.

The move comes at a time when the consolidation of hospital-based health systems has put new pressure on physician practices to redefine what they do in an accountable care world.

In an interview last week with ConvergenceRI, Mary Ellen Ashe, the executive director of Ortho Rhode Island, talked about how the vision was not just about consolidating the footprint of Ortho Rhode Island but shaping the future of how a private physicians’ group practice evolves, not as the appendage of a hospital-based health system, but as a new kind of health care delivery system.

“We see this, and orthopedics really lends itself to this: we see this as creating an orthopedic delivery system,” Ashe said.

When you think in terms of doing bundled payments, Ashe continued, “We were the first to do commercial bundled payments in this market; we were the first to do same-day urgent care in this market. We’ve been the first to do same-day outpatient surgery for joints in this market.”

As Ortho Rhode Island has put together its statewide orthopedic practice, Ashe said, “We look at patient satisfaction; we look at the value, we look at quality – being able to provide and to have protocols for the entire episode of care. We are really building a musculoskeletal network [of care].”

The new full-service orthopedic delivery system that Ortho Rhode Island is building is a network based upon collaboration, Ashe emphasized. “We collaborate. It is very collaborative. We collaborate with our hospital partners; we collaborate with our acute care partners. We collaborate with our vendors.”

Here is the ConvergenceRI interview with Mary Ellen Ashe, executive director of Ortho Rhode Island, the state’s largest orthopedic group practice, as it builds its own orthopedic delivery system, with construction about to begin on a new facility planned in Warwick.

ConvergenceRI: Where are you in the process? Is the building moving forward?
The building is moving forward. On Dec. 12, we go for our final approval [before the Warwick Planning Board]. We hope to break ground, to begin clearing land in January.

ConvergenceRI: Will the R.I. Department of Health be involved in this initial approval process?
No; we are a private practice. Not in a medical office building, for a provider ambulatory service center [ASC].

The Department of Health does need to inspect the ASC; that is subject to Department of Health regulations.

We will also seek [to obtain] certification, such as Medicare certification, and triple A ASF [the Ambulatory Association of Accreditation for Ambulatory Surgery Facilities] certification.

ConvergenceRI: With this new facility, you will be establishing a headquarters for all the different practices. Is that a good way to describe it?
We are. [It is part of] our strategic plan. In that strategic plan, we have continually tried to think like a patient.

We are continually reaching out to our strategic partners, and our stakeholders – our patients, our referring doctors and the payers, as we design this building, and we’re asking them: What do they want?

We’re collaborating with them along the way. As we design this building, we’re designing it with access in mind.

Yes, we are consolidating offices. At one point, we had 17 offices. When all is said and done, we will continue to have offices throughout the state, but we will have a lot less offices.

ConvergenceRI: There appears to be some recent activity by University Orthopedics in Warwick. Is it like McDonald’s, when they open a new location, Wendy’s opens next door, and Burger King opens up across the street? Is there a similar kind of methodology as to why University Orthopedics is also opening new facilities in Warwick?
[laughter] I can’t speak to their strategic plan. Again, we are looking at our patients, our referrals, what our patients want. And, we’re making sure that we have access to where our stakeholders want us to be.

ConvergenceRI: I have also seen that Brown Physicians Inc. has been much more active in advertising and becoming sponsors of events. I still don’t understand fully the business model of Brown Physicians Inc. Do you have any insights into the way that physician group practices are expanding and changing statewide?
I think the market will continue to evolve for private practices. I think we’re seeing more and more consolidation of private practices, whether that is through full mergers or collaborations and practice integration.

ConvergenceRI: Is that a process of vertical integration or horizontal integration?
I think you’re going to see both. The first phase of integration is horizontal integration. I think as the market matures in the private practice market, you’ll see more vertical integration.

ConvergenceRI: Every time I talk with you, I get the impression that you are one of the smarter folks in the delivery of health care in Rhode Island, articulating a clear vision of what you are doing and why. Which is different that many other practitioners of health care, who still seem to be stuck on the existing treadmill. I do not know if you are adverse to compliments.


ConvergenceRI: Ortho Rhode Island appears to have a clear focus and vision of what you want to do in the evolving marketplace that is consistently different than what other health systems are pursuing. Can you talk a bit more about that vision, about what you see that the patients want, what the providers want, what the payers want?
ASHE: We see this as creating an orthopedic delivery system. We have been leaders in doing bundled payments. We were the first to do commercial bundled payments in this market; we were the first to do same-day urgent care in this market. We’ve been the first to do same-day outpatient surgery for joints in this market.

As we have put together a statewide orthopedic practice, we look at patient satisfaction. Part of that is looking at the episode of care, [looking] at quality, being able to provide, and to have the protocols for, the entire episode of care.

It is a full-service network, and we collaborate. We collaborate with our hospital partners, we collaborate with our acute care partners; we collaborate with our vendors.

ConvergenceRI: Does that include University Orthopedics?
We have a very good working relationship with them. And, especially on things like quality initiatives. We see a lot of value in working with University Orthopedics on quality initiatives.

ConvergenceRI: How does this effort to create a new orthopedic delivery of care system impact health IT and interoperability? Which health IT system do you use?
We work with Centricity [GE Healthcare’s EMR system].

ConvergenceRI: When you look at the new merger between CVS and Aetna, and the plans by Amazon, Berkshire Hathaway and Goldman Sachs to curb medical costs and improve customer satisfaction, it is still unclear to me how those models of Big Data analysis are going to change the delivery of health care around what patients want.

I may be too cynical about this, but I believe what patients really want is have a continual relationship the same provider.
I think the health care industry has been behind on their investment in technology. You can look at the lessons learned by other industries, such as banking.

Before online banking, before the advent of being able to use ATMs throughout the country, you had to go to your local branch; everything was siloed. So, health care is catching up in terms of its investments in health IT.

ConvergenceRI: Should I be less cynical about the process, and take a longer-term view?
In terms of the EHR world, I don’t think, if you were to ask physicians or patients: Is there really a benefit? Do they love today’s versions of what’s available in the EHR market? I don’t think you’re going to find a lot of satisfaction.

I think we are in a phase, and it is evolving.

I think the future, as you look at what the big tech companies are doing, what Apple is doing, what Amazon is doing, I think we’re on the verge of the next evolution in health care IT.

Right now, with medical records, the onus is on physicians’ practices.

I think the next phase is really about the medical record belonging to the patient. I think that is what we’re transitioning to.

It’s not there yet; it’s going to take time.

ConvergenceRI: So the question is: who owns the data?
Right. It is going to be a long process.

ConvergenceRI: The Mindfulness Center at Brown, which is centered on the practice of mindfulness, they have a number of ongoing pilot programs. Their clinical research has demonstrated that the practice of mindfulness appears to improve the outcomes for cardiovascular health. The Mindfulness Center has applied the practices to stress and anxiety with Brown students, with all the data being captured by FitBit devices.

Last year, when I did a story about The Mindfulness Center, I asked: who owns the data? And, it turned out that FitBit does. I asked if they saw that as a potential conflict; they said they did not.

Afterward, I wondered, at what point do students say: No, I don’t want FitBit to know about this.
There are a lot of questions that are going to have to be answered. But I think the industry is changing. We’re in the midst of change. But we’re going to be using EHRs for the near future.

ConvergenceRI: One of the interesting questions for an orthopedic practice, one that does knee replacements and hip replacements, with plans to implant sensors as part of the procedure to help the patient and the physician monitor the recovery, providing data about are you doing enough exercise, how much pain is there, my question is: who owns that data and how it is used? Is it the insurance company? Is it Ortho Rhode Island? Is it the patient? Who determines how the data is shared?
That’s a very good question.

One of the things that we’re doing is to invest more resources in data analytics. We’re investing in terms of really being able to participate in quality initiatives.

ConvergenceRI: What do you mean by quality initiatives?
Quality initiatives such as patient reported outcomes, in which the data is reported to a registry that is worldwide.

The focus is on patient reported outcomes; patients agreed to participate in this. And, you monitor them for a specific time period, such as two years, to see the outcomes. We do that now.

Each year, it becomes more sophisticated, and the outcomes data become more sophisticated, and the database continues to grow.

ConvergenceRI: Do you have a relationship with IlluminOss [a medical device firm based in East Providence with an innovative bone fracture repair system]?
We don’t.

But we are living in a very exciting time when it comes to new technology, including the technology we that we currently use in surgery, and the technology that we are evaluating.

The use of robotic technology, we are involved with different companies, and with computer-assisted technology, it’s a very, very exciting time.


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