EXECUTIVE SUMMARY:

Healthcare organizations moving into the uncharted territory of accountable care organizations (ACOs) face technological and organizational challenges that could stop their fledgling attempts in their tracks. Many have embraced health IT as the key to establishing successful ACO models.

The CIOs of healthcare systems that are creating accountable care organizations make no bones about it: without health IT to knit together healthcare providers and patients, ACOs will fail.

“Healthcare is an information business,” notes Bruce D. Smith, CIO of Advocate Healthcare in Chicago. “The ability to access that information and move it around is going to be a key factor for ACOs to operate efficiently.”

Fledgling ACOs face some daunting health IT challenges: the inadequate integration of enterprise systems, the need to develop or enhance computerized physician order entry (CPOE) capability, the slow uptake of electronic health records (EHRs) in private practices, a lack of national standards for health information exchange (HIE), and poor communication between inpatient, ambulatory-care, and post-acute care providers.

To cope with these difficulties, healthcare organizations have developed an array of strategies. To move data between hospitals and clinics, for example, they're using everything from physician portals to HIEs to integration software such as Amalga (supplied by Microsoft Corp., Redmond, Wash.) and Carefx (from Carefx Corp., Scottsdale, Ariz.). The healthcare systems we examined are using data warehouses, registries, and claims data from health plans to do population health management and track where patients go for care. But there's a general recognition that all of this is in a very preliminary stage.

Here are four case studies showing how some leading organizations are planning to use health IT in their ACO projects.

NORTON HEALTH CARE

Louisville, Ky.-based Norton Health Care, which is preparing for an ACO pilot with Humana Inc., Louisville, Ky., will employ health IT to find out whether the ACO lowers the cost and improves the quality of patient care. “The one thing that's going to make this successful or a failure is collecting the data and using it to show that the ACO is making a difference,” explains Steve Heilman, M.D., vice president and chief medical officer of Norton.

Norton's ACO will initially cover four of its five hospitals and 300 of its 400 employed physicians. While all of the hospitals have EHRs in different stages, Norton is just beginning to roll out the Verona, Wis.-based Epic ambulatory care EHR to its outpatient clinics.

Norton is using Microsoft's Amalga HIE platform and Microsoft HealthVault to mine patient data and accelerate the process of information exchange among providers and patients. By combining Amalga's capabilities and the HealthVault personal health record (PHR) with EHR deployment, Heilman says, Norton will be able to create a patient-centric view of clinical, patient-entered, and claims data that will measure how the ACO is affecting quality and efficiency. Humana's claims data, Heilman adds, will be used mainly to track where patients are going and what's being done for them outside the Norton organization.

At the same time, Norton will send clinical information, including hospital data, to patient PHRs on HealthVault. Patients can push care summaries (in the form of continuity of care documents (CCDs) or continuity of care records (CCRs) to their physicians. This will immediately give primary care doctors who don't work in the hospital more inpatient data than they have now.

Down the line, Heilman says, Norton will probably replicate its core health information system within Amalga, giving physicians who have an Amalga viewer the ability to see all inpatient data. As more doctors get their own EHRs, the Norton hospitals hope to gain online access to ambulatory care records, as well.

Using Amalga as a data warehouse, Norton will build disease registries to help manage its patient population. It will also integrate home monitoring tools with the HealthVault PHR so that clinicians can see how patients are doing at home.

Heilman doesn't envision problems in using Norton's current administrative systems to measure the cost of care in the ACO, because the only patients involved initially will be those in Norton's and Humana's own health plans, and only employed doctors will participate in the ACO. But when the ACO encompasses independent doctors, and Norton has to share ACO savings with them, he says, “that's a different scenario. Structuring that will be a little interesting and dicey.”

MOUNTAIN STATES HEALTH ALLIANCE

Mountain States Health Alliance (MSHA), a Johnson City, Tenn.-based healthcare system with eight hospitals in Tennessee and five in Virginia, is developing an ACO that will encompass the tri-city market where its facilities are located. All of MSHA's hospitals and its 250 employed physicians, as well as many of its 1,000 community doctors, will be involved in the ACO. Fortified by the lessons it has learned in the ACO collaboratives of the Premier healthcare alliance, Charlotte, N.C. (which also includes the Premier group purchasing organization), MSHA plans to launch its new organization in July, using its own employees as guinea pigs. By Jan. 1, 2012, MSHA hopes to be ready to participate in the Medicare shared-savings program.

Health IT is the “glue” on which the success of the ACO will depend, declares Morris Seligman, M.D., senior vice president and chief medical officer of MSHA. The core strategy is to use information systems to measure and manage population health. In addition, health IT will be required to improve care coordination and to supply actionable data at the point of care.

MSHA's Tennessee hospitals use a hospital information system from Siemens Medical Solutions USA Inc., Malvern, Pa., whereas its recently acquired Virginia facilities have other kinds of systems, Seligman says. The plan is to roll out Siemens' information solutions to all MSHA hospitals by the end of 2012. Concurrently, MSHA will begin installing CPOE across its enterprise.

MSHA's ambulatory care clinics recently implemented the Allscripts (Chicago) EHR, and Siemens has promised to create an interface between its inpatient EHR and Allscripts. Siemens will also build a data warehouse that includes inpatient and outpatient information. This data warehouse will serve as an overall registry that tracks patients' health status and analyzes their healthcare needs, Seligman says.

“Our goal is to have the same kind of data stream that Geisinger Health Care has,” he notes, adding that he has visited Geisinger, in Danbury, Penn., several times. “‘Mary Jane hasn't had her last mammogram, time to get her in here.’ Or somebody is due for a pneumovax. That's all part of the data warehouse.”

The biggest challenge for MSHA-as it is for other healthcare systems developing ACOs-is the low level of EHR adoption by community physicians. While private-practice doctors are helping MSHA plan its ACO, most of their colleagues still lack EHRs, and those who have them aren't necessarily using Allscripts.

MSHA may provide some incentives and/or technical aid to get community doctors onboard, says Seligman. Meanwhile, it has developed a physician portal that will provide view-only access to patient information. Down the road, MSHA may have Siemens interface with CareSpark, a local HIE in Kingsport, Tenn., so that doctors on disparate EHRs can link to the ACO information system.

MSHA is also looking at creating an internal HIE for information exchange between its own physicians and facilities, Seligman says. If it does that, the HIE will be interfaced with the EHRs of community doctors.

Without the ability to exchange information among all providers, he adds, “it's going to be very difficult to manage and measure care.” And he sees this going beyond what's required to show meaningful use of a hospital or outpatient EHR. “If you're going to manage populations, and have a mixture of employed and community physicians, you need to move that information electronically.”

ADVOCATE HEALTH CARE

In Chicago, Advocate Health Care, which has entered a shared-savings agreement with Blue Cross Blue Shield of Illinois, has gone further than most organizations in infusing its ACO with health IT capabilities. Yet Advocate is still struggling to close the loop between its inpatient, outpatient, and post-acute-care systems.

“We do have pretty good integration of information within the hospital setting,” says Bruce Smith, CIO of Advocate Health Care. “When you come into the ER, whether you're an outpatient or an inpatient, all that information is pretty well tied together. Probably 85 percent is digitized and electronically captured. The inpatient-outpatient EHR connection is pretty solid. The holes are in the physician offices. All of that acute care information is available to our physicians in their offices. But right now, their office systems don't completely integrate. That's what we're looking at doing now.”

About 500 of the 800 physicians in the Advocate Medical Group have implemented the Allscripts Enterprise EHR. Advocate's 12 hospitals in the Chicago area are using Cerner (Kansas City, Mo.), and the organization is building a bidirectional interface between Cerner and Allscripts that's scheduled for completion by the end of this year. Advocate is also using Allscripts' discharge planning, and home care systems-two important pieces of the post-acute-care puzzle.

Advocate Physician Partners (APP), a care management and contracting organization, includes 3,600 doctors on the staffs of Advocate hospitals. The community doctors in APP have decided to adopt the eClinicalWorks (Westborough, Mass.) EHR. Smith says that Advocate plans to build an interface between Cerner and eClinicalWorks, and eventually, between eClinicalWorks and Allscripts. The healthcare system is also working with a middleware vendor, Carefx, to set up a portal that will sit on top of all three systems, allowing doctors to view combined data at the point of care.

Advocate also plans to incorporate claims data from the Illinois Blues in its ACO database. Like Norton, it will use this data to track patients when they go outside the ACO for care.

Smith points out that ACOs will add major levels of complexity to administrative systems. Those systems will have to be able to track which patients are assigned to the ACO, attribute them to particular physicians, measure cost savings, and divide those savings among participating providers.

While Smith would prefer to have a more integrated system and do fewer interfaces, he observes that ACOs are far too complex for any single vendor to address.

“There's no single system that will take care of everything, so you're stuck with the fact that you're going to have multiple vendors, multiple architectures, multiple databases, multiple platforms. Getting those to integrate and work together is going to be a strong challenge.”

AURORA HEALTH CARE

In contrast to Advocate, Aurora Health Care, located in Milwaukee, Wis., views health IT integration as the optimal approach for building an ACO. Partly for that reason, the big integrated delivery network (IDN) is now converting to Epic from Cerner, which it currently uses in its 15 hospitals and most of its 175 clinics.

According to Philip Loftus, Aurora's CIO, the Epic system will allow connectivity with Aurora's home care agency and closer integration between its hospitals and clinics. That's difficult with the current information system, Loftus explains, because Cerner was deployed over a period of time, and as it was upgraded, each hospital developed slightly different workflows. “We want to promote a best-practice standard of care and deploy it across the whole Aurora system.”

The integrated approach leaves out independent physician practices that are on different EHRs. But Aurora has less need for community doctors than do many other organizations that are forming ACOs. Its 1,400 employed physicians include most of the primary care physicians it will require for its ACO, says Patrick Falvey, the system's senior vice president and chief integration officer.

Aurora has devised several strategies for connecting with practices outside its system. First, it will host Epic for some groups, such as the Baker Clinic in Green Bay, Wis., which is already partnered with the Aurora hospital there. Second, Epic offers an HIE that its customers can use to communicate with other Epic users, and many other Wisconsin groups use that product. Loftus says Aurora will consider hosting other EHRs for smaller practices, and it will also take advantage of community HIEs. Finally, it will build the capability to exchange CCDs with disparate EHRs.

Aurora also plans to increase its connectivity with post-acute-care providers. Besides linking to the Visiting Nurse Association (VNA) home care agency, the IDN will interface with VNA's hospice, and it will consider ways to hook up with long-term-care facilities.

During the transition to Epic, Aurora will use the 15 years' worth of patient data it has accumulated in its data warehouse to do population health management. The IDN already does medical management in its own health plan and for its employees and has built decision support tools to drive quality improvement. In addition, Falvey says, it will rely on automated outreach methods and a patient portal to supplement the EHR alerts and warnings that providers see at the point of care.

On the administrative side, Falvey points out, Aurora will have to develop methods to identify the Medicare patients who are attributed to the ACO and to attribute each episode of care to a provider. Moreover, because the Medicare shared-savings program allows patients to “float in and out of” their ACO relationships, Aurora will have to track where these patients are going, using its own claims data and a statewide database to which health plans contribute their data.

Overall, Falvey summarizes, “Health IT is going to drive the ACO by engaging patients in their own care, by providing decision support, and by enabling providers to communicate through their EHR so they can find out what has happened with a patient, document what they did, and document where the patient goes next.”

Ken Terry is a feelance writer based in Sheffield, Mass. Healthcare Informatics 2011 May;28(5):16-22