Healthcare CIOs and industry experts expressed a variety of views following the March 31 release of the proposed rule for the development of accountable care organizations (ACOs) under federal healthcare reform.

Given the complexity of the 429-page rule—with two different reimbursement models, quality data reporting requirements, multiple levels of antitrust enforcement, and issues around beneficiary data-sharing opt-in/opt-out—it’s not surprising that many in the industry are still sorting through the implications of the proposed rule.

But interviews with healthcare CIOs and other industry experts this week reveal a range of concerns and perspectives on what could be one of the potentially transformative elements in the federal healthcare reform legislation package, the Affordable Care Act, passed in March 2010.

Some are already moving forward
Some of the healthcare IT leaders interviewed by the HCI editorial team work for organizations that have been steadily working towards integrated models already. That’s the case at the 20-hospital University of Pittsburgh Medical Center (UPMC) health system, says Jacqueline Dailey, who since January has served as vice president for IT solutions for medical science, research and patient-centered accountable care, for the integrated health system (previously, she was CIO of Children’s Hospital of Pittsburgh of UPMC).

“We were already moving in this direction by working in the payer-provider environment at UPMC,” Dailey says; UPMC, she notes, has its own UPMC Health Plan. “We have been working for years with the health plan to coordinate care better, to look at the results of how we take care of our patients on the provider side of the organization, and to improve that care,” she says.

In that context, Dailey says with regard to the proposed rule, “On a quick read-through, there is nothing that is particularly surprising to me from a technology standpoint. There is a lot of value in the use of technology, and for UPMC, the work it has done in the past 10 or 12 years, to embrace the use of technology in all aspects of our work as a health system, and integrated delivery network. We have been working with, not only our [physician] practices that are part of UPMC, but our affiliate practices to help them automate their offices as well, so we can exchange information more readily electronically, and more accurately electronically.”

Other healthcare IT executives are more concerned, among them Michael Sauk, vice president and CIO of the University of Wisconsin Hospitals and Clinics in Madison, Wis. “My concern in reading the summaries of the proposed regs is primarily with regard to the patient accountability to the plan,” Sauk says. “The idea that the patient could decide they’ll have a specialty service performed at a competing organization, and that we’d be picking up the tab for it, that’s just scary to me. We’re at the University of Wisconsin, but the patient could go to the Mayo Clinic. Even if a patient is assigned to you, they don’t have to go to you.”

Sauk says he sees considerable financial risk in that scenario. More specifically with regard to the IT requirements of ACO development, he says, “I’ve talked to multiple CIOs whose sites have been ACO demonstration sites for CMS in recent years. And I’ve asked them a simple question: from the day the ACO was first talked about to today, what tasks did CIOs have to accomplish? And CIOs from two academic medical centers have told me, ‘We’ve had to do nothing’”—in other words, their organizations simply participated in the CMS demonstration project constituted as they already were, with no need to redesign any of their information systems or data-sharing capabilities for that purpose.

Sauk adds that UW is a stage 7 organization, according to the HIMSS Analytics EMR development schematic, and even his organization will face significant development work in data warehouse and other areas, in order to potentially participate in an ACO. “For a lot of hospitals, to be able to take in data from non-owned entities and track costs and the patient experience, will be next to impossible. We can definitely do it, but what will the cost impact be, and what will the impact be on other initiatives, such as ICD-10?” he says.

Experts see multiple issues
Industry experts following the developments around the ACO concept see a number of challenges, some of which they say leaders of provider organizations may not yet even have fully considered. “The disappointing thing about the ACO rules in the proposal stage is they have created a whole new set of quality reporting requirements for health delivery organizations, and this is on top of all the reporting requirements they currently have and all the new quality reporting requirements from the new HITECH/meaningful use incentive program,” says Jordan Battani, a principal research in the Waltham, Mass.-based Emerging Practices Group, a division of the Falls Church, Va.-based CSC. “There doesn’t seem to be much cross-fertilization in all these federal programs and interests in quality, and it reads a little like a pile-on,” she adds. “It would be great if all these could be coordinated into a master set of quality indicators. At initiation, it’s going to prove to be just an incredible challenge for everybody.”

Meanwhile, patient care organization leaders need to think very carefully and thoroughly about the change management aspects underlying ACO development work, says Ron Wince, president and CEO of the Mesa, Ariz.-based Guidon Performance Solutions, a consulting firm specializing in operations management and technology consulting.

“Those organizations at the higher end of maturity on the curve in terms of understanding processes will be able to benefit that,” Wince says. “It starts with the ability to actually measure quality,” he notes. Organizations that can already do so “will be a step ahead. I always go back to the core questions of how versus what. And I think the organizations that are further along on the ‘how’ piece will be more successful on this journey.” So, for example, being able to successfully map processes such as delivery of care for coronary artery bypass graft (CABG) surgery, and to be able to use formal performance improvement methodologies to improve care quality, service quality, and efficiency around such common procedures, will be essential to success in this new environment, he says.

Wince urges CIOs to “go back and revisit your IT governance and strategy: how are you going to run IT in a very fast-paced landscape? Having an EMR will be table stakes just to get into the game,” he insists. “Second, you need to look at your technology portfolio and try to simplify it as best as you can, and to focus in on what your most capable technologies are.” Above all, he says, “Don’t chase shiny objects”—meaning, focus on what technologies can do, not simply on adding technologies for the sake of doing so.

UPMC’s Dailey says she and her colleagues are very aware of the major challenges their already advanced organization faces going forward. “The integration of all of our applications, how we make sure we have the right patient everywhere and that patient is known in our system, is a challenge; and making sure that the technology that the end-users are using is up and running,” will also be important, she adds. “Our service and our consistency and reliability of the technology must be as near to 100 percent as possible,” she notes, adding that the interfacing of different information systems will be another key to success going forward.