As the accountable care revolution evolves forward across the U.S. healthcare industry, some of the most innovative organizations in the country have committed themselves very firmly to its success. In the Boston metro area, the Steward Health Care System—which encompasses 11 hospitals and 2,700 physicians (600 of whom are employed)— is participating in the Pioneer ACO [accountable care organization] program as Steward Health Care Network. The Pioneer ACOs are the tip of the spear in terms of working with the federal Centers for Medicare and Medicaid Services (CMS) to improve clinical outcomes and reduce costs, in the context of downside risk.
Steward Health Care Network joined the program along with the other Pioneers, on January 1, 2012. Dominique Morgan-Solomon, the ACO’s vice president of population health, spoke earlier this summer with HCI Editor-in-Chief Mark Hagland, for the magazine’s July-August cover story. Below are excerpts from Ms. Morgan-Solomon’s interview with Hagland earlier this summer.
When did you begin developing the infrastructure for the ACO?
A certain component of the infrastructure existed prior to 2012. Steward in general is very familiar with managing risk populations, which is one of the reasons leadership decided to participate in the program, because it aligns well with our Steward Community Care Model, which focuses on local care management and leveraging our PCP [primary care physician] network; and we had experience with managing populations with a budget and risk in mind. So a lot of that structure was there; some of the infrastructure needed to manage this population was being developed in the first quarter of 2012 anyway, as we were developing more robust care management and population health infrastructure, as well as data analytics.
And how big a team do you have?
We have over 60 people doing population health work on our team.
Has anything been really surprising, in terms of participation in the Pioneer ACO program?
I think we anticipated the run-of-the-mill pieces in terms of focusing on beneficiary engagement, and having to engage our providers in a very different way so that they’d understand the value proposition in participating in the program. I think some of the surprises have been around how quickly a year ends. One of the challenges of the Pioneer program is that the population turns over for us annually, so that by the time you’ve identified individuals, run the analytics on the population based on the claims that CMS has provided, which comes in February, you’re into June and July. So that quick turnaround was a bit surprising, because usually you have a bit of lead time to get engagement and look forward to a good 12 months to get it worked out.
Is there that significant of a population that’s changing every year?
Yes, it’s about 30-40 percent; and all the Pioneer ACOs have been having that experience. And so you really have to then think about how you impact someone right away. And typically with care management and population health, you’re trying to institute interventions upstream, and that’s challenging. And because the ACO population is a Medicare population, the majority of whom are 65 (though there are some under 65)—and you’d think there are a lot of differences between the Medicare and commercial populations, but there really haven’t been.
So getting things in place has been the biggest challenge?
That’s been one. And the first year, there obviously were a lot of upfront pieces. The most difficult piece, though, has been beneficiary engagement. So one of the challenges we’ve had, because we’ve been trying to do population health for all groups covered; the challenge has been, that’s great on this side, but it requires beneficiaries’ knowledge and engagement with us as a provider. And they’re not always sure they belong to us. So you’ll potentially have a beneficiary who has seen one of our providers a few years ago, maybe via a specialist in our network, but their primary care provider is with a different system. So one of the challenges has been, how do you get these beneficiaries engaged, because in some cases, they haven’t realized they’re attributed to us. And they have to opt in, and they get letters from CMS, but you can imagine, of course, that there are populations that may not have caregivers who explain everything to them; so we’ve had to get creative there.
Do you have care managers and case managers who are doing that kind of work?
Care managers are doing many things; they’re nurses, so they’re engaging people, of course, around their care. But there’s got to be upfront work as well. We have a member services team; and marketing is involved as well. But it’s a challenge that we’ve all faced.
Are all the hospitals on the same EHR?
We probably are one of the most heterogeneous networks in the country, per electronic health records. Every hospital has its own EHR, and physicians have their own EHRs. And often, with affiliate physicians, they’re on different EHRs. So we have upwards of several hundred different databases, even with the same EHRs in some cases. In that regard, data integration is obviously a huge focus for us, especially this year.
How are you tackling that?
We’ve spent a significant amount of time surveying the IT data integration market to find a partner that had some experience working with very heterogeneous data, to take a long-term strategic approach, to come up with a way to integrate a variety of different systems, and partner with a vendor that was really good at the normalization process and cleaning the data and filtering it back into a universal system that would give us the analytics to drive performance. So we’ve opted to do that, while also having a short-term strategy around the key data elements we need right now, to put into a data warehouse structure.
Have you chosen a vendor?
Yes, Optum/Humedica [the Boston-based Humedica, an Optum Company]. We began talking to them a number of months ago, but the work began a couple of months ago [in the spring of 2014].
What are some of the key data elements involved in this analytics work?
And this is not just for our ACO; we’re in a significant number of other risk contracts. We have a rich, robust claims data repository, because we’ve been receiving claims data from payers for a while. This is really about the EHR-based clinical data, for the reporting of quality measures. The measure sets may not always be the same, the data elements are similar. So obviously, they include the demographic data elements, but also labs, pharmaceutical data, diagnosis codes, assessments, including tobacco and depression screening data, and diagnostic imaging results, too. The next step, after putting this data into structured fields, is to get into natural language processing to access things in provider notes; because ejection fraction, for instance, is typically inside a note and not in structured notes.
When did you begin to apply natural language processing to this work?
That’s part of the longer-term work that Humedica’s doing now. They essentially pull everything from the EHR.
What have been the biggest lessons learned so far, with regard to your Pioneer ACO participation?
I think one of the biggest learnings for us has been to not try to boil the ocean—you only have so many resources and so much time, so it’s important to focus our efforts on the biggest levers in terms of being able to be successful and to build upon that year over year, as opposed to trying to do everything all at once; and I think we’ve actually done a really good job of that. And there’s a time to move quickly, and a time to assess. And that’s certainly true in terms of vendor selection. It was worth it to take the time to really vet the capabilities of various vendors, because what vendors say they can do and what they can actually do, is very different.
I think one of the other lessons learned is certainly to get provider engagement upstream. And the further upstream we can get provider engagement, the better. They’re one of our biggest assets. So we’ve infused medical directors and associate medical directors into so much of the work we’ve done, and involved them in the messaging to clinicians. And actually, our marketing department drives a lot of that; we have a monthly newsletter to keep clinicians abreast of what’s going on; that’s helped them feel more connected. And the same is true in terms of upstream connection with beneficiaries.
And the biggest lessons learned with regard to IT?
Make sure you’re talking to the right person within the IT infrastructure. Sometimes it takes a little bit more time than you’d think.
Do you have a CIO?
Oh, definitely. And we partner with IT a lot. Especially when you’re bringing in outside people, you need to be making sure you’re having those broader conversation. And the IT leadership has definitely been part of the leadership discussions as we’ve been moving forward.
What would your advice for our core audience of CIOs, CMIOs, and other healthcare IT leaders?
I would say that there’s value in their understanding the workflow, from the perspective of the clinicians and the care teams. We’re fortunate that our CIO and healthcare IT leaders are very open-minded and will say, walk me through this; because often, they have an insight that we don’t have. I would also say, and this is a good thing here—we don’t ever want IT to be a barrier to not being able to manage a population, etc.; so for IT to have an internal service mentality, I think that’s important. In order to be more efficient and more effective, as we take on more populations, it won’t be about adding more bodies, but about becoming more efficient and effective. So as things need to be tweaked or enhanced, there will have to be that service mentality from IT. And we’ve been fortunate here to have an IT group that gets that.
Any last thoughts?
I would say, for people entering this journey, for them to take the time to learn from those of us who have, no pun intended, pioneering. And keep your eyes on the prize: everything involved here is about delivering better healthcare to patients, and that can be of value to your provider organization; and because we’re delivering it in a more cost-effective way, it will ultimately add value to care delivery.