In an industry full of incredibly busy executives, Chuck Podesta must surely count as one of the busiest. Podesta has for years been senior vice president and CIO of Fletcher Allen Health Care, a Burlington, Vermont-based health system encompassing one academic medical center and numerous ambulatory sites and physician practices. But there’s so much more to it than that. To begin with, in January 2012, Fletcher Allen created a corporate umbrella, Fletcher Allen Partners, which brought into the network Elizabethtown Hospital, a critical-access hospital in Elizabethtown, New York; and then in January 2013, Central Vermont Medical Center, a 100-bed community hospital in Berlin, Vermont, and 250-bed Champlain Valley Physicians Hospital in Plattsburgh, New York.
But wait—there’s much more. First, the leaders at Fletcher Allen launched their Medicare Shared Savings Program accountable care organization (ACO), OneCare ACO, in January 2013; that ACO encompasses all 14 hospitals in the state of Vermont, as well as Dartmouth-Hitchcock Medical Center, located over the border in Lebanon, New Hampshire (Dartmouth-Hitchcock cares for numerous residents of eastern Vermont). According to Podesta, with its current estimate of 52,000 patients involved, OneCare ACO is the fourth-largest in the country. What’s more, Podesta notes, the state of Vermont, based on the healthcare reform law it passed in 2011, is requiring that all individuals signing up for health insurance using the state’s health insurance exchange, be enrolled in OneCare ACO. At the same time, Podesta and his colleagues are awaiting word that the state of Vermont will include Medicaid and commercial health plan enrollees in OneCare as well. The resulting total could reach upwards of 150,000, in a state with a population of 600,000.
Indeed, one explicit strategy of Green Mountain Care, Vermont’s healthcare reform law, passed in 2011, is to get 90 percent of Vermonters into risk-based health insurance plans as possible, in order to promote value-based purchasing and improve care delivery.
And yet there’s still more. The Fletcher Allen organization has been involved from the start with VITL, Vermont Information Technology Leaders, the statewide, 850-provider-strong health information exchange (HIE). One advantage for all those involved in VITL is a state requirement that all providers in Vermont connect to VITL.
Podesta spoke recently with HCI Editor-in-Chief Mark Hagland regarding his involvement in all these activities, and the broad implications of all this work. This is Part 1 of a two-part article.
You have so much going on, it’s amazing. Tell me a bit about your HIE activity of late?
On the HIE side, we’re contracting with VITL, our state-sanctioned HIE. The state passed a law that all the providers in the state are required to connect to VITL, which has been very helpful. And OneCare is working very closely with VITL to move the EHR [electronic health record] portion of what we need into the strategy. So you get the CMS claims data and load that in, but to do predictive analytics, you need to add in the lab data and biometrics data from the patient, and you need that from the EHR. And we have over 20 different EHR vendors involved in OneCare. And the only mechanism is to pull that into there through Medicity, which is providing the interface engine to pull the data into VITL. And then on our big data strategy, we’re in a consortium with Dartmouth-Hitchcock, Maine Health, and Eastern Maine Health System, and that’s called the Northern New England Accountable Care Collaborative (NNEACC).
That’s a learning collaborative?
It’s more than that; it’s the collaborative that is creating the ACO dashboard and is consuming Medicare data.
You’re sharing data in order to benchmark performance, then?
Yes, basically, the bigger the denominator of patients, the better the analytics you’ll get. And certainly while our PHI from the organizations is all segmented, we can do deidentified queries across 2 million patients instead of 700,000. So you’re going to get better results with 100,000 diabetics, say, versus 25,000 diabetics. So the larger the number of these patients in the high-cost chronic diseases that you’re trying to control, the better off you’re going to be. And two of the four—Dartmouth-Hitchcock and Eastern Maine—are pioneer ACOs. And being able to learn from that is important. And the nice thing is, it’s a single data repository, it’s a data warehouse, so we don’t have four separate warehouses involved. And Recombinant, owned by Deloitte now, has created the applications—the predictive analytics portion, the care management portion, etc.
Meanwhile, others, like Scripps and Texas Health Resources, are doing that. And that’s what I think you’ll see across the country. What makes sense is for these [collaborative organizations] to create databases of de-identified data that are as large as possible. On the other hand, it also creates challenges, because you’ve got to figure out the HIE solution across multiple states. To give you an example, Adirondack Health was launched in January of this year, and it encompasses both Fletcher Allen Health, and Champlain Valley Physician Hospital, our affiliate, and large physician practices and other hospitals, including Glens Falls Hospital in northern New York, as well. There are 25,000-28,000 in that ACO, which is an MSSP. They’re also going to use NNEACC as well. And that will allow us to drive up the numbers in our database and also to use the same tool.
And the HIE in northern New York if called HIXNY, and they’re very well-established. So VITL is working closely with HIXNY, to create an interstate transfer of information between two HIEs, which really gets to the goal of what the government’s trying to do with Healtheway. And Fletcher Allen, we only need to have our contract with VITL; we don’t have to have a separate contract with HIXNY as well. And they’ve been working very closely together.
You and your colleagues have been advancing in so many areas.
It’s very exciting, for sure!
What have your biggest learnings been so far in all this work?
A few things. One is that we’re calling it a learning healthcare system, which connotes that we’re continually learning from what we’re doing, and evolving as we go; as opposed to saying, this is what it’s going to look like, in a rigid way.
In other words, it’s all a very iterative process, correct?
Right, especially on the IT side. We’re trying to get people to stay very flexible. And that’s been one of the challenges, is that people tend to like concrete plans. And over the next year, from an IT perspective, people want to know what the plan is? And I can tell you the ten next things we're going to do with our EHR; and things we’ll do around meaningful use, and privacy and security. But I can’t tell you two years now what we’ll be doing.
And years ago, people used to want to try to do ten-year plans, but that’s ridiculous now, right?
Even three-year plans are ridiculous now. We’re essentially doing six-to-twelve-month plans and adjusting them as we go. Because for example, we’re doing clinical integration work among our four hospitals, and I didn’t know three months ago that we needed to integrate one service line from one hospital into a broader plan. And you know you’ve got to take risk, and you know the big things you need to do, so you march down the path. But you’re learning off the data.
We’re starting to get really good data, for example, about emergency department utilization across the state of Vermont, and there are pockets of high utilization and low utilization, and we’re just beginning to understand why. So we need to move where the data is telling us to move. And the stuff is expensive, and your CFOs want to know, over the next three or four years, what IT will cost us. And that’s very, very difficult to predict. So you’ve got to get your senior leaders and CEO and on board.
That’s the other challenge, to get them on board with new sets of expectations and thinking. And some of the CIOs who are really challenged and are having trouble are trying to manage under two- or three-year plans, and those plans keep getting blown apart, and so the CEO and CFO come to you and say, do you know what you’re doing? They start questioning what you’re doing. And so you have to say, I as much as I’d like to, these are the reasons I can’t do a three-year plan; but here’s what I can do. And certainly, some CIOs struggle more with it than others, and CEOs and CFOs struggle, too, because we’re talking big dollars, and shrinking margins.
But I do fear for my CIO colleagues across the country, because we’re all dealing with the same things; yet some are struggling more with those things than others.
In Part 2 of this article, Chuck Podesta will respond to questions about the meaningful use process.