EXECUTIVE SUMMARY:
With several healthcare reform-related programs already beginning to demand an extremely broad range of data reporting from providers, and the meaningful use process under HITECH continuing to move forward, healthcare IT leaders are faced as never before with a menu of data reporting mandates that are set to redraw the landscape of healthcare. In this cover story package, we look first at the overall picture, and then offer case studies from the pioneering organizations that are already moving forward into the future of healthcare, one organized around the industry's new accountability agenda.
Part I: The New Landscape of Accountability
With several mandates around data reporting coming out of various federal government initiatives these days, healthcare IT leaders are on the cusp of a new era, one that will not only be driven by data, but shaped by it as well. Given three mandatory programs and two voluntary programs coming out of the Patient Protection and Affordable Care Act (ACA)-the comprehensive federal healthcare reform legislation passed by the U.S. Congress and signed into law by President Barack Obama in March 2010; as well as the ongoing meaningful use process under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act, established through the federal stimulus program of February 2009-there has never been a time in the healthcare industry's history when data reporting requirements have been so intense and demanding.
ONE THING WE NOTED IN PUTTING TOGETHER THE WHITE PAPER IS THAT, WHEN PEOPLE WERE WRITING ABOUT HEALTHCARE REFORM, THEY KEPT USING THE FUTURE TENSE. AND WE NOTICED THAT SOME OF THE DATES DIDN'T SEEM ALL THAT FAR IN THE FUTURE. -JANE METZGER
Indeed, the complexity of the situation is such that industry experts are warning CIOs and other healthcare IT experts they need to be actively engaged right now in intensive work to satisfy all the requirements involved. Among the industry leaders in this area, Jane Metzger, principal researcher in the Waltham, Mass-based Global Institute for Emerging Healthcare Practices, a division of the Falls Church, Va.-based CSC, co-authored a white paper in August along with colleagues Caitlin Lorincz and Marta Arthur, entitled “The Hospital Agenda for Accountability,” which laid out the various data reporting requirements under healthcare reform and articulated the concept of the “new accountability agenda in healthcare” that the various programs represent.
When put together, the data reporting requirements are daunting in their breadth and scope, Metzger and her co-authors point out in their white paper (available at http://assets1.csc.com/health_services/downloads/CSC_Hospital_Agenda_for_Accountability.pdf). First, there are the requirements coming out of the three mandatory programs under healthcare, to be administered under the Medicare program: the value-based purchasing program, the readmissions reduction program, and the healthcare-acquired conditions reduction program. Then there are the requirements emerging out of the two broad voluntary programs under healthcare reform, also administered through Medicare: the accountable care organization (ACO) shared-savings program and the bundled payments shared-savings program. And of course, there are the many requirements under Stages 1 through 3 of the meaningful use process under the HITECH Act.
Not surprisingly, many hospital leaders will find the overlaps in the data demands involved in these various programs, as well as their overall breadth of scope, confusing and challenging. Such diverse areas as mortality statistics, infections, patient falls, the administration of certain types of drugs, the provision of patient discharge summaries, and patient experience measures, are all implicated. Not surprisingly also, each of these programs involves its own particular complexities, including around the fact that some of the data regimes are based on calendar years and others on fiscal years.
“One thing we noted in putting together the white paper,” Metzger says, “is that, when people were writing about healthcare reform, they kept using the future tense. And we noticed that some of the dates didn't seem all that far in the future. For example,” she notes, “probably the most significant element is data collection for chart-abstracted measures for the first year of value-based purchasing, which started on July 1, 2011. So we decided that some of these elements weren't well-understood. And the ACA is over 1,000 pages and is very complex. These programs under the ACA are on separate timetables, and have different elements to them.” Unless healthcare leaders begin to educate themselves rapidly and thoroughly in the data reporting requirements under the three mandatory programs (and certainly the two voluntary ones, too, if they are interested in participating in those), Metzger argues, they will quite quickly fall perilously behind.
In preparing the white paper, Metzger continues, “We decided also to sort them by timeframe, by looking at the first year in which measurement for a measure will actually influence reimbursement. That cuts through all these many different applicable dates. And when we did that,” she says, “it turned out, as we suspected, that the future is now; and regardless of what happens with the ACO rule and whether hospitals participate in the shared-savings program or not, there is this pretty significant accountability agenda hitting the industry. And none of these other programs are voluntary.”
REGARDLESS OF WHAT HAPPENS WITH THE ACO RULE AND WHETHER HOSPITALS PARTICIPATE IN THE SHARED-SAVINGS PROGRAM OR NOT, THERE IS THIS PRETTY SIGNIFICANT ACCOUNTABILITY AGENDA HITTING THE INDUSTRY. -JANE METZGER
The bottom line? The data reporting requirements under the three mandatory healthcare reform-triggered programs under Medicare are a here-and-now concern, not some futuristic menu of optional issues to consider.
What's more, with reimbursement-cut provisions in all three of the mandatory programs beginning in the last few years, the stakes are high. “By 2015, when the healthcare-acquired conditions program kicks in,” Metzger notes, “low-performing hospitals could potentially lose 3 percent of their Medicare reimbursement because of HACs [healthcare-aquired conditions], on top of 1.5 percent under the value-based purchasing program. In fiscal year 2015, the bottom-performing hospitals will lose 1.5 percent from the value-based purchasing program, 3 percent from the readmissions reduction program, and a further percentage from the HAC program; so it starts adding up; it's a big deal.”
For CIOs, CMIOs, and other healthcare IT leaders, the implications are clear, Metzger says. In her view, what will be key is that, “Going forward, data capture will be the foundation not just for informed care-that you have a medical record that's complete-but what will be essential will be the data that you need for measurement, and bringing that measurement into real time, so you can track patients, and if there are gaps in care, take care of those in real time.”
PART II: THE PIONEERS
Case Study: At Allina, Drilling Down to Actionable Change
One thing that is becoming clear over time is that the patient care organizations-hospitals, medical groups, and integrated health systems-that are moving forward comprehensively to improve patient safety, care quality, clinician effectiveness, efficiency, and cost-effectiveness all at once, are also the ones whose potential to be winners under the new accountability agenda in healthcare is greatest. The leaders of those organizations have committed themselves and their teams to doing what's right for patients-and yes, for purchasers-by pushing hard to improve the core care delivery processes that make a difference. And they are looking systematically at the potential for change, and very often using formal performance improvement methodologies, such as lean management, Six Sigma, the Toyota Production System, and PDCA (plan-do-check-act) in order to map and improve processes. Not surprisingly, such efforts are drilling down into areas that all the mandatory and voluntary programs under the ACA are working to improve, as well.
MEDICATION RECONCILIATION AT THE POINT OF DISCHARGE HAS BEEN A WEAK LINK, SO WE BROKE DOWN THE WORK, AND HAVE CREATED SEVERAL ALERTS TO LET DOCTORS AND NURSES KNOW IF CHANGES HAVE OCCURRED AT THE TIME OF DISCHARGE. -MICHAEL SHRIFT, M.D.
And it is in such organizations that clinician, IT, and clinical informaticist leaders are most often able to drill down the numerous layers needed in order to analyze underlying problems and really correct them. Such processes are taking place on a broad scale at the Minneapolis-based Allina Hospitals and Clinics, where leaders like Michael Shrift, M.D., the system's CMIO and vice president for clinical knowledge management, are guiding their colleagues through optimization work that is improving performance across the health system's 11 hospitals and 100-plus clinics.
Shrift is leading his team off 45 clinical informaticists, in concert with IT leaders and leaders from Excellian (Allina's name for a suite of clinical applications, including Epic's EMR), measurement and analytics leaders and clinician leaders across the Allina organization, in a wide variety of improvement initiatives. “We're blessed to have such strong clinical leaders at Allina; so the organization's clinical priorities are fairly easy to define,” Shrift says. “As we focus on priorities among our clinical service lines, such as the cardiovascular service line, and specifically for heart failure or acute MI, or for readmission prevention, our teams are specifically assigned to each of these pieces of work, to break down the workflow into pieces that can be either made into evidence-based practice or best-practice. the work is then hardwired by handing it off to the technical teams whose members design solutions. We work very closely with the clinicians and their support staff throughout this process, to find out which decision support tools most effectively support the care.”
There are numerous examples of progress and process change that Shrift could cite, but one initiative that exemplifies the disciplined sort of work that he and his colleagues are engaged in is in the area of medication reconciliation at the point of discharge.
“Medication reconciliation at the point of discharge has been a weak link,” Shrift explains. “So we broke down the work, and have created several alerts to let doctors and nurses know if changes have occurred at the time of discharge. We're pretty good during the time when the patient is in the bed, but it's during that physical transition time between bed and front door when last-minute changes affect medication lists.” During that time, he notes, “Patients and families are stressed, and it's a confusing time, so there isn't 100-percent accuracy at the point of discharge.” Indeed, Shrift and his colleagues in clinical informatics have estimated the historical level of inaccuracy as averaging as high as 20 percent, with some of the inaccuracies being omissions, with other problems including last-minute changes in medications that aren't communicated to a patient's family.
So what Shrift and his colleagues in clinical informatics have done is to alert the appropriate physician and nurse if changes have been made to a patient's medications list just prior to discharge. The other has been to embed a helpful “smart list” of medications into the EMR, in order to essentially make it more difficult for doctors to make mistakes in this area.
“Our clinical leaders strongly support this approach to making it easy to do the right thing at the right time,” Shrift says. “If you're doing the right thing, we don't bug you; but if you're doing the wrong thing, we use guardrails and cattle prods to improve patient safety.”
IF YOU'RE DOING THE RIGHT THING, WE DON'T WANT TO BUG YOU; BUT IF YOU'RE DOING THE WRONG THING, WE USE GUARDRAILS AND CATTLE PRODS TO IMPROVE PATIENT SAFETY. -MICHAEL SCHRIFT, M.D.
While it is precisely these types of laser-like, drilled-down interventions in process that will create the patient safety and care quality improvements desperately needed in the healthcare system, Shrift is under no illusion that any of this will be easy. So when asked for his advice, he readily responds, “Stay humble, because you won't get it right every time. And if you're not making a few informatics mistakes in the pursuit of service of great patient care, you're not trying hard enough. So it just takes a humble attitude to keep at it.
Continuing in that vein, Shrift says, “The other thing I would say is to not do it alone. We are incredibly lucky at Allina to have world-class clinicians, robust performance and analytics resources, an IS and Excellian team who won the HIMSS Davies award a few years ago, and a very driven leadership. Collaborating with them each day makes a big difference.” What's more, he says, “There are many other organizations doing this; and as I say, many heads think better than one. So learn from others. That's why we're involved in the CMIO Collaborative,” which includes some of the most well-known pioneering organizations in the country (the University of Pittsburgh Medical Center system, the Geisinger Health System, the Sentara Health system, the Cleveland Clinic health system, Texas Health Resources, Intermountain Healthcare, and Group Health Cooperative of Puget Sound), with leaders from all the participant organizations in that collaborative actively working with all the others to learn from one another.
In the end, underscores, making serious progress on the quality and patient safety requirements coming out of healthcare reform and other sources will require such sustained, deep, and broad work. But he and his colleagues continue to thrive in the environment of continuous performance improvement they've created, as they move forward on many fronts at once.
Case Study: Doctors Measuring Up in Indiana
While physicians nationwide are beginning to move forward in reporting on their patient care outcomes, the vast majority are still in the earliest stages in this important area. But a small number of multispecialty medical groups are showing the way when it comes to laying the IT and data foundations for routine, comprehensive outcomes reporting, and one of those is the American Health Network (AHN), an Indianapolis-based multispecialty medical group with 230 providers (about 170 of whom are physicians), providing patient care out of about 85 locations in Indiana and Ohio.
At AHN, CIO Debbie Pehler and manager of payer contracting Don Stumpp have been helping to firmly lay those foundations for their organization. They have been facilitating the participation of AHN in an Indiana program sponsored by Anthem Healthcare called Quality Health First, whose outcomes reporting initiative currently encompasses 26 commonly used quality measures, such as diabetic patients who have had a hemoglobin A1C screening test in the past 12 months, and common women's and children's health measures, such as provision of mammograms.
The AHN physicians are making gradual but steady progress in a number of areas. For example, Stumpp notes, “We had a compliance rate of 53 percent at the beginning of last year with regard to the percentage of patients ages 3 to 6 who had had a well-baby visit; by the end of last year, it was 69 percent.” Similarly, results on measures including hemoglobin A1C screenings and Chlamydia screenings have both improved. Importantly, of course, Stumpp notes, the AHN physicians are competing for patients and market share with non-AHN physicians whose outcomes are also increasingly being measured by these large health plans.
What's more, says, Pehler, “The measures are very similar to the clinical quality measures in meaningful use.” As a result, building and enhancing the infrastructure for one purpose is supporting the infrastructure for the other. Furthermore, the process has had not only the support, but indeed the participation, of the highest levels of AHN management, which has made all the difference, she says. “Our CEO, Dr. Ben Park, has probably been the person driving most of these efforts,” she notes. “In fact, he's actually developed a lot of the reports that we call ‘patient-on-a-page.'” The patient-on-a-page report, she explains, is literally a one-page printout given to each physician just before she or he sees a patient for a patient visit. The ability to provide the doctors with this particular tool has strongly enhanced their preparedness when seeing patients, not to mention their satisfaction with the organization's EMR capabilities, she reports.
In terms of the mechanics, “We extract information out of the NextGen database”-the organization's EMR is from the Horsham, Pa.-based NextGen Healthcare-“and we pull that information nightly, so that every morning, the physicians who choose to get this report have it emailed to them,” Pehler explains.
The patient-on-a-page tool also in turn triggers reminders to physicians to ensure that patients are receiving the kinds of screenings and tests being measured by the Quality Health First program, so all of these different elements of AHN's efforts reinforce each other.
Moving forward on all these fronts has taken considerable effort over time, and of course, has required considerable collaboration between the quality and IT departments at AHN. “It took a long time to work through back-office functional issues-correcting the data, getting things right, even working on the attribution of patients,” Stumpp reports. “Now we're working at the front-end elements-are we making sure that Mrs. Smith gets the right tests and meds when she comes in for a visit, that kind of thing.” But the results speak for themselves, he says. “What we're trying to do is to emphasize for the physicians that they should be giving health care, not just sick care; and we're trying to encourage patients to engage with us in all these elements of care.”
In the end, Stumpp says, “I think that transparency, not just in cost but also in quality, is being sought after by payers and purchasers, and ultimately, patients.” While he adds that “I don't know that consumers are yet looking at that data to a large extent, it would certainly help to be able to demonstrate good processes and outcomes.” And, he says, “I certainly would hate to be the physician who doesn't do the proper screenings and doesn't have the best outcomes.” Fortunately for them, the doctors at AHN have proven their value-based purchasing mettle, earning more than $1 million each year over the past two full years in which they've participated in the Quality Health First program.
Case Study: Preparing for ACO Participation in New Jersey
At the 230-bed Meadowlands Hospital and Medical Center in Secaucus, N.J., preliminary preparations are underway for laying the groundwork, both strategic and IT, for participation in the ACO shared-savings program under Medicare. Interestingly, the background of Tomas Gregorio, the hospital's president and CEO, reflects the importance of strategic IT involvement in such preparations, as Gregorio was until last year the CIO at nearby Newark Beth Israel Medical Center. But, says Gregorio, “We're a for-profit hospital, and the investors decided to put a CIO in the CEO seat, because of technology becoming so important to achieving results now in healthcare.” In fact, Gregorio joined Meadowlands in May of last year, with the expectation of being made CEO in 2012, but circumstances changed, and he was put into the CEO position earlier this year. (The hospital itself is still relatively very new, having opened its doors only in December of last year.)
Under his leadership, “We've created the Hudson County Health Care Alliance,” Gregorio reports. “The mission of the organization is to integrate physicians in the community, the hospital, and the house calls we do for the patients in the community. This is our ACO concept,” he says, adding that not only do he and his colleagues plan to apply to become participants in the Medicare shared-savings program, they are at the same time working to build a collaborative with physicians to support that concept. As of press time, a small number of physicians had already joined, with the expectation of more than 100 doctors participating over time.
Importantly, Gregorio and his colleagues have not been approaching the local doctors empty-handed. “As a technology-based hospital, a 100-percent-paperless hospital, we're tracking patients in their homes in collaboration with GE Intel; and we are developing home monitoring that will actually help keep readmission rates down,” he reports. “We're interested in creating that entire ecosystem,” he stresses; he and his colleagues are in the startup phase of building the technology infrastructure for live-monitoring of patients in their homes, and are hoping to begin a phased rollout of patient home-monitoring using that technology, starting in the first quarter of 2012. They are also continuing to enhance their core cloud-computing capabilities, as they plan to add both back-end nurse case management support capabilities and front-end consumer tools (including alerts around medications, etc.) to their menu of technologies. All of these are complementary to one another, Gregorio emphasizes, and all will support Meadowlands' strategizing forward towards ACO participation.
In the end, Gregorio says, he and his colleagues at Meadowlands are convinced that success in the ACO arena will mean thinking like a health plan, to the extent that intensive care coordination and management and across-the-continuum thinking will be required for accountable care success. In that context, laying the IT foundations will be absolutely essential to the success of all hospital organizations seeking to capture reimbursement across the continuum of care.
Discussion: A Long, Sometimes-Winding, Journey
Those healthcare IT leaders who've been involved in metrics-driven improvement for a long time have a number of pieces of wisdom to share with their colleagues. “We've gained experience in meeting multiple data requirements, including adhering to stringent data definitions and submission requirements, and have learned how to capture, harvest, and report data consistently,” says Steven Riney, vice president and CIO of Methodist Medical Center, which until Oct. 1 had been a standalone community hospital in Peoria, Ill. (on Oct. 1, Methodist joined the Des Moines-based Iowa Health System). “And as a result,” Riney says, “we've gained experience in collaborating as a team-with clinicians, IT, decision support, and performance improvement people all working together-to make these gains. That's the cultural piece that will serve us as we go forward into the next phase.”
In fact, Riney notes, “We've probably pulled in a half-million dollars over the last few years” as a high-performing participant in the CMS/Premier HQID (Hospital Quality Incentive Demonstration) program, whose success provided the basis for the design of the value-based purchasing program under Medicare. And that experience, Riney says, is the kind that hospitals and medical groups of all types will need to have in order to succeed under healthcare reform.
Still, Riney cautions, even with such experience, going forward into any of the three mandatory or two voluntary programs will not be a slam-dunk for any patient care organization. In fact, Riney and his colleagues determined this summer, based on the preliminary ACO rule, that the potential for making payment gains from the ACO shared-savings program was simply not strong enough for them. “We could save millions of dollars and get $50,000 in reimbursement, so it didn't make sense for us to participate,” he said in the early autumn, before the final rule was released.
Randy Thomas, a vice president at the Charlotte-based Premier Inc. alliance who has been involved in the HQID demonstration project, says that the work involved in HQID “was a great learning for the country. It involved a lot of hard work for the hospitals that have participated,” she says, “and the country learned that if you focus on quality, you can improve outcomes and bend the cost curve at the same time.” What's more, she says, “As we start to look at the quality measures related to meaningful use, we'll see that the organizations that have made strides through the HQID program are much better-positioned to take the information that comes out of their EHRs and even further excel in quality improvement.”
In the end, Riney concludes, the biggest and most core challenges going forward will be around “the non-technical, cultural stuff.” So what should CIOs, CMIOs, and other healthcare IT leaders be doing right now? “Find a place to plug in,” he says. “I was able to do that with Premier through HQID, and then with Premier's ACO collaborative. So, plug in somewhere and get your hands dirty.”
WE'VE GAINED EXPERIENCE IN COLLABORATING AS A TEAM-WITH CLINICIANS, IT, DECISION SUPPORT, AND PERFORMANCE IMPROVEMENT PEOPLE ALL WORKING TOGETHER-TO MAKE THESE GAINS. THAT'S THE CULTURAL PIECE THAT WILL SERVE US AS WE GO FORWARD INTO THE NEXT PHASE. -STEVEN RINEY
Healthcare Informatics 2011 December;28(12):08-17