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From the Lens of a CIO: Moving Forward on Value-Based Care Efforts Without a Roadmap (Part 1)

July 12, 2016
by Heather Landi
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This past April, 14 CIOs from leading healthcare organizations convened at the Scottsdale Institute’s Spring CIO Summit in Arizona to discuss the most important health IT-related challenges facing CIOs and to share insights on key IT-enabled strategies for value-based care.

Driven by the accelerating trend toward alternative payment models that reward quality of care rather than volume of services rendered, many of the organizations represented at the Scottsdale Institute CIO Summit have been preparing for value-based care with the development of clinically integrated networks for some time, while others are just getting started. Last year’s passage of the Medicare Access and CHIP Reauthorization Act (MACRA), which rapidly accelerates the transition to value-based payments, has especially spurred health systems to optimize and expand their clinically integrated networks, which presents CIOs with a number of IT challenges.

The Summit was hosted by the Scottsdale Institute, a Minn.-based not-for-profit membership organization of health systems advanced in IT, and sponsored by Impact Advisors, a Naperville, Ill.-based healthcare IT consultancy and moderated by Ralph Wakerly of Minneapolis-based consultancy C-Suite Resources. Insights from the discussions at the spring CIO Summit are outlined in the report, “Creating Clinically Integrated Networks: Challenges, Successes, Lessons Learned.” The group identified several lessons learned to be successful in a value-based environment, including the need for CIOs to be willing to make strategic decisions and learn quickly from their mistakes, the importance of data analytics, how to manage the complexity of new partnerships and the need for collaborative leadership moving forward.

Following the Summit, Healthcare Informatics Assistant Editor Heather Landi spoke with two CIOs who were in attendance—George Conklin, Senior VP and CIO at the Irving, Texas-based Christus Health, a 60-hospital integrated healthcare delivery system, and Mary Alice Annecharico, Senior VP and CIO at Henry Ford Health System, a five-hospital health system based in Detroit—as well as Tonya Edwards, M.D., physician executive at Impact Advisors. In Part 1 of this story, Healthcare Informatics provides an inside look at building clinically integrated networks from the lens of CIOs and the challenges they face. Below are excerpts of those discussions with Conklin, Annecharico and Edwards.

What was the general mood of the CIOs involved in the discussions at the CIO Summit?


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Edwards: There was a lot of energy and a sense of excitement about what the future holds, but also some nervousness about what the future holds, because so much is changing so very rapidly. Leaders from several organizations actually pointed out that there really is no roadmap. They are trying to make decisions quickly, be nimble and move forward on a path, but not knowing necessarily if the path they are going down is the right path. That said, there was a lot of excitement about being able to do some new things that could help drive health systems forward much faster, particularly around the area of analytics.

Conklin: Concerned, with a lot of focus around security, but also there was a sense of, How can we work together better to help protect all of us?

Cybersecurity wasn’t one of the key findings in the report from the CIO Summit, but it sounds as if it was discussed, so what were some of the takeaways from those discussions?

Annecharico: [Cybersecurity] was peppered throughout the conversations that we were having throughout the entire conference. It is a growing burden for our organizations to be able to keep the bad actors out and to manage our responsibilities at the federal level with managing the privacy and security of our data.

Mary Alice Annecharico

Conklin: Everybody is as focused as we are on it and there is a keen amount of interest. There was a concern relative to our ability to be able to respond effectively to all of the different evolving kinds of attacks that are occurring out there. There is a lot more cooperation amongst us, and evolving new ways of communicating when one of us sees something or is attacked by something, and communicating it out to other group members, and even enlisting each other to help in the event of an attack.

The CIO Summit specifically focused on the IT challenges of developing clinical integrated networks. Why is this a crucial time for healthcare organizations to build or expand their clinically integrated networks?

Conklin: What we’re seeing is, and particularly within Christus, is our traditional business is mainly focused around acute care, so hospital episodes. What we’ve now seeing is a steady and consistent decrease in admissions and discharges and, as a result, revenues, and increasing demand for newer, higher-end technologies that require capital investments. Patients are getting their healthcare somewhere else, such as free-standing ERs, surgery centers, doctor’s offices and clinics that are constructed to be convenient to them and to handle episodic needs for treatment and services, but are not geared up to be able to handle the long-term and evolving needs of people who might have multiple co-comorbidities. So our focus in our healthcare systems, and universally across all the Scottsdale Institute membership, is beginning to develop a more balanced portfolio of services and products that network together community-based entities and physicians to provide care where patients want it. And, where these services are not present, the focus is to put in physician practices, establish free-standing ERs, imaging centers and surgery centers. The big positive being that all these things are tied together into a service network so that your information moves with you as you need different levels or types of care. That’s the big focus from an IT perspective—how do we bring in new partners to integrate into our networks, how do we build out and establish these new centers ourselves and how do we tie them all together? One of the other things we’re doing as well is we’re beginning to move into the health plan space and become an insurer on our own.

Annecharico: The IT challenges of creating clinical integrated networks is an important topic for many reasons, but the major reasons deal with our population health environments and the thirst for us to be able to organize data and use it meaningfully, to manage our local populations, and also the health and welfare of our regions and our nations. Population health is a major driver to help us take a look at cohort data differently and help us to use data to create an insight-driven environment. The other major component that is of value to Henry Ford and other organizations at the Summit is to figure out how to leverage contracting in a way that enables us to have fair value from our payers. Right now, each one of our organizations are fighting with our insurance companies to get the best value out of fair cost. This will enable us to do that, because we are looking at a diversity of services as well as the basic foundation for primary care and we’re moving into ambulatory care. We are able to speak with a larger voice. But it’s important that as our inpatient populations continue to decline, we’re realizing that we have economies of scale to move much of that into the ambulatory market. At the same time, we don’t get reimbursed the same way, and it’s taking more density, more concentrated services to be able to attain a normal state,. Most of us have seen up to 30 percent of our revenues declining from the payment models that exist today and that shift is really requiring us to use data differently to help us think smarter and more strategically.

One of the key recommendations for CIOs from the report was “fail fast, learn fast.” What does this mean?

Edwards: I think the main reason speed is important is there’s a sense of this acceleration of change, particularly with some of the things that have gone on the last few years, with the CMS announcements related to changing over to more value-based payment. After the January 2015 announcements, when MACRA came along, people started to take all of the anticipated changes much more seriously. And, now we are starting to feel quite a bit of pressure because folks know that, while the first year is 2019, the first performance period starts six months from now. People are beginning to understand that speed is going to be very important to get to a place where we can perform well under MACRA, and then also the rapidly changing commercial market, there’s been an acceleration on value-based payment there as well.

Tonya Edward, M.D.

Conklin: There is a need for speed, and a need for capital. And so given the prior context of decreased admissions, the capital bases are shrinking for us, so at the time when we need to make heavy investments in IT and build out those kinds of centers and things I’ve talked about, such as new doctor’s practices, we’re also having shrinking basic cash to be able to do that. One of the challenges is certainly doing it fast, but also doing it inexpensively, which means moving toward more standardization and a cookie cutter build-out of these places. So when you go into a free-standing ER or doctor’s practice, the look and feel is particularly a Christus Health look and feel and it’s the same format and construction for these sites regardless of where they are located.

Annecharico: We can’t know it all or do it all, but to be successful you have to make strategic decisions and move forward quickly and nimbly. If you have an idea and can assemble a business strategy around it and can really look at your return on investment, then you can move forward and put it into a small enough environment. It’s about whether you can learn from what’s working and not working and be resilient enough to either make adaptations or bail on that and try something else.

It may very well be that you have a bridge strategy where you want to get to the other side of the bridge and you have a couple of stops and starts to get there, but you ultimately know what your goal is. I’ll give you an example. For us, during the period of time that we were implementing Epic, we worked on a framework to transform our clinical operations. We did the entire organization, all of the inpatient and ambulatory as well as all of our revenue cycle consolidation, in a 16-month period of time. And with that, we were also trying to build the future state of what our enterprise data warehousing strategy was. And, we realized that one of the partners that we chose was slipping and falling too often and so we had to create a very defined timeline and indicate the deliverables that needed to be managed, the quality and the content of them, and, if not, then we will void the relationship. That’s difficult to do when you have multi-million dollar contracts, but we were so clear and gave it enough attention that we had defined the scope of the work as well as our outcomes. We were realizing that we couldn’t deliver our products to our end-user communities because we had this barrier in there, so along the same line, we decided that this was simply not working, but what we did do, at the same time, was we started building a bridge strategy to get us over the hump and evolve a permanent strategy right behind it. So that we ultimately had a better solution and a better line of products that we could deliver to our communities of users.

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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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