Industry experts and healthcare IT leaders agree that the recently released proposed rule on the creation of accountable care organizations (ACOs) is offering a heady mix of opportunity and risk, and that laying the IT foundation for success under ACO initiatives will be massively challenging for the vast majority of patient care organizations nationwide. Those a bit further along on the journey say that interoperability, connectivity, and the leveraging of clinical IT for intensive care management and data analysis will be essential to ACO success.
On March 31, when the federal Centers for Medicare and Medicaid Services (CMS) released its proposed rule for accountable care organization (ACO) development under federal healthcare reform, it unleashed a torrent of comment, interest, and concern across the healthcare industry. In releasing the proposed rule, CMS both fulfilled an explicit requirement under the Accountable Care Act (ACA), the federal healthcare reform legislation passed in March 2010, and also signaled to the industry its intentions around one major element of reimbursement reform.
YOU'VE GOT TO BE ABLE TO GET INTO YOUR ELECTRONIC HEALTH RECORD AND CREATE DISEASE REGISTRIES, HELP [Patients] MANAGE THEIR DISEASES, BE ABLE TO INTERVENE TO PREVENT EMERGENCY DEPARTMENT VISITS.-DONALD W. FISHER, PH.D.
Indeed, taken together with new mandates around value-based purchasing, readmissions reduction, and non-payment for healthcare-acquired infections and conditions and “never” events, the creation of the voluntary ACOs program points towards a healthcare reimbursement system moving rapidly away from no-strings fee-for-service payment for hospital and other services, and towards a system strongly modified in favor of various contingencies around payment.
And while many provider leaders are interested in becoming involved in the Medicare shared savings program around ACOs-and in many cases, shared-savings programs in the commercial health insurance market, as well-many expressed some alarm, following the March 31 proposed rule release, at some of the elements in the proposed rule. These include elements around payment itself (most especially the downside risk elements in the “two-sided risk” model being offered alongside a “one-sided risk” model) and in the level of information technology and data management challenges involved.
For example, under the proposed rule, 50 percent of physicians participating in any ACO would have to be “meaningful users,” as defined by the Health Information Technology for Economic and Clinical Health (HITECH) Act, a requirement that many provider executives consider unrealistic in the short term. What's more, the interoperability and connectivity requirements appear daunting to many in patient care organizations.
MORE THAN SIMPLE EHR IMPLEMENTATION
All aspects of ACO development will prove challenging if the specific requirements of the proposed rule remain in place in later stages, says Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Va.-based American Medical Group Association (AMGA). In terms of the level of nationwide physician group preparation for ACO development, Fisher says, “I think it runs the gamut; the very small solo practices and smallest groups are simply not ready. But some of the larger multidisciplinary medical groups that have a significant enough primary care base and relationships with hospitals, and that have some level of electronic health record, and some experience with population health management, and are looking beyond one-patient-at-a-time episodic care, are more ready.” That being said, he emphasizes that “As far as the electronic health record, it's not just having an EHR that stores patient information isn't sufficient,” Fisher notes; “you've got to be able to get into your electronic health record and create disease registries, help [patients] manage their diseases, be able to intervene to prevent emergency department visits, and so on.”
Key Elements of the ACOs Proposed Rule
Key elements of the 429-page proposed rule on accountable care organizations released on March 31 by the federal Centers for Medicare and Medicaid Services (CMS) include the following:
The creation of two different risk models: “one-sided” and “two-sided,” in which provider collaboratives forming ACOs can either go solely for potential payment bonuses under the ACO shared savings program under Medicare, or can accept downside risk as well, for a higher potential reward.
Among the requirements in the proposed rule is one that states that at least 50 percent of physicians participating in an ACO must be “meaningful users” according to the HITECH Act's definition of meaningful use.
CMS officials indicated in the proposed rule that they expect between 75 and 150 ACOs to emerge during the initial phase of ACO development.
In fact, Fisher notes, nine of the 10 organizations involved in the Medicare ACO demonstration project that preceded the passage of the ACA were AMGA member organizations, and have been sharing their learnings from the demo project with their fellow AMGA organizational members. And, he adds, “One of the things that they talked about was bringing the electronic health record to life, and leveraging it to manage care for patients.” Those demonstration project participant organizations that were successful “had systems that would allow them to reengineer their care processes,” helping to pair, for example, a diabetic patient with a nurse educator at an early point in care management, and developing teams of analysts to examine care processes and outcomes, and suggest process and cost improvements.
WE ALREADY COMMUNICATE WITH THE HEALTH PLAN ABOUT THE CARE OF PATIENTS WITHIN OUR OWN HEALTH SYSTEM, SO WE'VE HAD A LITTLE BIT OF TIME TO EXAMINE WHAT THE COORDINATION OF CARE FOR PATIENTS LOOKS LIKE.-JACQUeLINE DAILEY
WE'RE TALKING TO SOME FOLKS WHO WANT TO MOVE FORWARD ON THE ACO FRONT BUT WHO AREN'T EVEN STABLE YET IN TERMS OF EMR DEVELOPMENT.-KEITH FIGLIOLI
PREPARING IN PITTSBURGH
On the multi-hospital system side of the industry, if there's anyone who could speak to the challenges and opportunities, it would be Jacqueline Dailey of the University of Pittsburgh Medical Center (UPMC) health system. Dailey, until December 31 had been CIO at Children's Hospital of Pittsburgh, part of the UPMC system; on January 1 she took on the title of vice president for IT solutions for medical science, research, and patient-centered accountable care. As her title indicates, she is laying the strategic IT foundations for ACO development for the 20-hospital system.
Part of what has put UPMC in a good position with regard to the ACO concept, Dailey says, is the fact that UPMC has its own health plan. “And we already communicate with the health plan about the care of patients within our own health system, so we've had a little bit of time to examine what the coordination of care for patients looks like,” she says. Of course, the reality is that “It is complicated, when you're stratifying patients; when you're managing care across sites and venues; when you're trying to perform strong analytics; and all of those are key. So we have had a little bit of a head start, and a lot of what we've done from a technology standpoint, is to perform in a coordinated way. “
Their work with the Pittsburgh-based dbMotion on semantic interoperability, Dailey says, has made a major difference in creating the interoperability and connectivity needed to fuel the data exchanges needed for ACO work. As Dailey explains it, “dbMotion is not just a way to connect Epic and Cerner [the system's core outpatient and inpatient EHR systems]; you have data beyond those systems that really needs to be brought together, through registry work and analytics work. And where we're at right now-we're aligning everybody on the same electronic record.” Most importantly so far, “We've really had a head start in terms of using dbMotion to provide aggregated views, and we're using dbMotion as our health information exchange platform as well,” she adds, referring to the fact that health information exchange will most certainly be a core component of successful ACOs.
A NATIONWIDE COLLABORATIVE
Even as individual patient care organizations and individual regional collaboratives begin to move forward to lay the IT foundation for accountable care, one national organization is already speeding ahead with work that its participants believe will benefit the entire industry. Indeed, reports Keith Figlioli, senior vice president of healthcare informatics at the Charlotte-based Premier Health Alliance, his organization, whose membership includes more than 2,500 hospital organizations nationwide, earlier this year created a collaborative to work on IT issues for accountable care, with a starting membership of 17 hospital and health system CIOs.
“There's an overall ACO collaborative” at Premier, Figlioli reports, and within that collaborative, a Population Health and Data Management Workgroup has been established. “The charge for this group has been, how do we put together this model?” he says. “And we looked at the HIMSS Analytics EMR schematic, and put the charge to the group to create something similar for ACOs. If you think about meaningful use, everybody's trying to figure out how to strategize forward.” There are three main layers of activity that will be required, he says-baseline infrastructure needs; then, the transactional layer; and finally, the level of activity involving business intelligence and population analytics.
Figlioli urges that CIOs demand strategic clarity from their c-suites and boards of directors, a kind of clarity he says is often missing right now among healthcare executives eager to get on the ACO bandwagon. “We're talking to some folks who want to move forward on the ACO front but who aren't even stable yet in terms of EMR development,” he says. “So part of the creation of this model has to do with helping people with baseline stuff. For example, if you don't have a standard EMPI [enterprise master patient index] across all your systems, don't even think about ACOs. And in terms of HIE [health information exchange], there are multiple layers to what that means. There's one layer specifically proprietary to your provider, which requires just getting your house in order, and then going regional.” As Premier's collaborative moves forward, he says its participant CIOs will continue to add to their learnings in terms of key steps and the sequencing of actions to support ACO-centric IT development.
THE BIGGEST CHALLENGE SO FAR HAS BEEN DATA EXCHANGE, BECAUSE OUR INITIATIVE HAS INVOLVED DIFFERENT ORGANIZATIONS WITH DIFFERENT POLICIES AROUND EXCHANGING INFORMATION.-CRAIG LANWAY
WE'RE REALLY PUTTING OUR HOPES ON NATURAL LANGUAGE PROCESSING, TO TAKE BLOBS OF DATA AND TURN THEM INTO SOMETHING.-DAVID MUNTZ
MEDICAL GROUPS' REGIONAL EXPERIENCES
In the San Francisco Bay area, some medical groups and hospitals have already had some introductory ACO-type experience on the commercial health plan side of things, including Hill Physicians Medical Group, the San Ramon-based independent practice association that encompasses more than 2,600 physicians. A project currently operating among Hill Physicians Medical Group, the 40-hospital, San Francisco-based Catholic Healthcare West, and the San Francisco-based Blue Shield of California, has been focused on reducing costs and improving care management and outcomes for the 41,000 members of the Sacramento-based California Public Employees' Retirement System (CalPERS) living in the Sacramento metro area.
Making a variety of different types of connections is crucial to the success of any project like this, says Craig Lanway, Hill's CIO. “You want to control readmits to the hospital, so when someone is discharged, you have to make sure they have an appointment to see their primary care physician; and you also have to make sure you've done medication reconciliation; and that you're controlling ER visits,” Lanway says.
“There's a lot of case management involved,” Lanway adds. “And a lot of this involves setting up access to the EHR so that the case managers and discharge planners could see both the inpatient and outpatient EHR.”
In the end, Lanway says, “The biggest challenge so far has been data exchange, because our initiative has involved different organizations with different policies around exchanging information. So we had to wade through the legal aspects of what we had to share and how, and make sure it was done securely. And just the simplest thing, like identifying the patient across the hospital, medical group, and health plan, was a challenge, because we had different identifiers. “The other challenge,” he says, “has been accurately identifying the costs, as we try to measure costs across the system.”
David Muntz, senior vice president and CIO of the 14-hospital, Dallas-based Baylor Health Care System, says, “Connectivity is going to be a big issue” in ACO development, as will be “the workflow implications of specialty-specific clinical information systems. “But the most challenging IT issue,” Muntz warns, “is going to be the need for semantic interoperability, to identify the key data elements” required for data sharing, reporting, and analysis. In that regard, he says, “We're really putting our hopes on natural language processing, to take blobs of data and turn them into something.” Muntz says he also sees tremendously steep challenges in quickly trying to build the strong trust between hospitals and physicians in order to be able to share data and information freely, to make ACOs successful. Fortunately, he notes, his organization already has a decade and a half of experience in just such trust-building.
Meanwhile, Brad Benton, national account leader in the New York-based National Health Care Practice at KPMG, says, “My advice to CIOs would be, as difficult as it is, and I recognize the challenge, you have to be thinking about the future as you're implementing currently. I think there's a concept around sustainability that applies here: you're spending 30, 40, 50 million dollars for an electronic health record; and if you're just slamming the thing in and not thinking about how it will support accountable care, it will be a major challenge to demonstrate to the c-suite the return on investment for that technology.”
Healthcare Informatics 2011 July;28(7):8-12