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Survey: Interoperability, Cost Continue to Hold Back ACOs

September 25, 2014
by Rajiv Leventhal
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Premier, eHealth Initiative survey suggests many ACOs lack mobile applications and face high costs

A recent survey of 62 accountable care organization (ACO) participants revealed that 100 percent of respondents have trouble gaining access to data outside of their organizations. Although most ACOs have the health IT in place to improve clinical quality, poor interoperability across systems and providers remains their biggest barrier, according to the survey conducted by the Charlotte, N.C.-based Premier, Inc. and the eHealth Initiative.

Compounding the challenge of accessing and sharing data is the fact that 88 percent of the ACOs face significant obstacles in integrating data from disparate sources, and 83 percent report challenges integrating technology analytics into workflow—barriers that become more acute as ACOs add new platforms or build on their expansive network of medical settings. As ACOs collect data from more sources, they also report concerns about interoperability and data management. Interoperability of disparate systems is a significant challenge for 95 percent of organizations using health IT, and could be limiting the abilities of ACOs to exchange data.

On a Sept. 24 press call discussing the survey results, Bryan Bowles, Premier's vice president for population health solution management, said that the concern regarding interoperability comes as no surprise to him. “In this new care delivery model, you have to deal with physician practices and disparate electronic health record (EHR) systems to get access to that data,” Bowles said. “How do you negotiate the rights to that adjudicated claims data with payers?  Getting access to that and other ambulatory data, and integrating it together is very difficult. Most organizations don’t have the skill set for that or the data warehouse capability,” he said.

Reflecting the provider frustration with interoperability problems, the cost and return-on-investment (ROI) of health IT has become a crippling concern for organizations today, cited in the survey as a key barrier to further implementations by at least 90 percent of respondents. “While accountable care organizations are providing quality care for many patients, even more could be accomplished if interoperability issues were addressed,” said Jennifer Covich Bordenick, CEO, eHealth Initiative. “However, the cost of interoperability can be prohibitive for many organizations.”

Other ACO challenges that were cited include: workflow integration (88 percent); lack of provider engagement (73 percent); lack of trained staff (69 percent); and lack of consensus on quality benchmarks and measures (67 percent). “If you have physicians that are affiliated, but independent, you need access to their data and need them to act in alignment with how physicians in the ACO will act. There are some really interesting relationships there,” Bowles said, adding that many of these challenges are interrelated. “Disease registries are based on data coming out of electronic health records. You have your data warehouse where you have your inpatient data from the EHR, ambulatory data, and adjudicated claims coming from payers. You have the master patient index, which is certainly is central to knowing which patients are which across those systems,” he said.

Also on the press call was Elizabeth Hammack, associate general counsel at the Cleveland, Ohio-based University Hospitals Health System, which provides care through three accountable care organizations—a Pediatric ACO, a Medicare ACO and an Employee ACO. “Every ACO is witnessing these challenges, and solutions that we have in place now might not be very relevant in a few years,” Hammack said. “Trying to hit a moving target is one of major challenges in health IT right now.”

Nathan Hunt, director of operations at University Hospitals Accountable Care Organization (UHACO), added that the barriers become tougher when you’re dealing with the outpatient environment and different physician practices. “You want to make known what the goals are for each population and put guidelines in place for the measurements we need to accomplish,” he said.  “And then you want to adapt to each individual physician group workflow as far as how they will use the technology. That’s your best chance at making an ACO successful.”

While the diversity of health IT systems and data sources available vary across organizations, the majority of surveyed ACOs pull information from fewer than 10 different data platforms. However, as ACOs pull data from more sources, they also report lower abilities to leverage their health IT infrastructure to support care coordination, patient engagement, physician payment and contract adjudication, population health management, and quality measurement.

“Even when ACOs have successfully adopted and merged health IT systems, they aren’t able to effectively leverage data and analytics to derive value out of their investments given the pervasive issues with data quality, liquidity and access, as well as issues with integrating data from disparate sources,” said Keith J. Figlioli, Premier’s senior vice president of healthcare informatics and member of the Office of the National Coordinator’s Health IT (ONC) Standards Committee. “The survey proves this is a pervasive problem among ACOs, and it could stymie the long-term vision for ACO cost and quality improvements if not addressed.” 

Additionally, the majority of survey participants report having a health IT infrastructure that can support quality measurement, population health management, and physician payment and contract adjudication. Core IT components include an EHR (86 percent); a disease registry (74 percent); a data warehouse (68 percent); and a clinical decision support system (58 percent).


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• The Vendor Community needs to look deeper into what and how they're addressing interoperability. In our experience, we recognize a number of technical as well as organizational roadblocks to successful exchange of information.
We hope with that ONC, Federal agencies, Congress, Chief Innovation Officers, CTOs and CIOs, Analytic Officers, Chief Data Officers, industry and the Federal procurement process will be promoting the importance of Testing. As both public and private sectors plan for current and future initiatives, it is important to recognize and mitigate the following risks:
• For those Large Federal Health Programs (focused on integration)
o Interoperability and conformance testing should be built into the entire software development lifecycle (agile)
o The importance of true independent (3rd party) testing
• For Health Systems and other Organizations
o Compliant Product (Vendors who prove “Continuous” Interoperability)
o Proven Technical Stacks (challenges)

Focus on the importance of testing for interoperability and standards conformance in the electronic exchange of information. The lists stakeholders in the first paragraph have the opportunity to mobilize the community to participate in the building and testing of standards-based, interoperability solutions while promoting innovation. Some proposed strategies to consider include:
• Support Automated Platform for Test Case Execution
• Encourage Best Practices for Audits and Work Flow Lifecycle of Testing
• Support an Environment for Re-Use of Testing Tools/Test Cases
• Promote Beyond “Happy Path Testing (peer-to-peer), ensure Negative Testing”
• Encourage the adoption and use of Standardized Test Data
• Support and enables Communities of Interest for a shared testing environment
• Promote Industry Reporting Metrics on how well their products and services ensure interoperability and not vendor lock-in.

Federal agency and provider communities should advocate the following to ensure "Continuous" Interoperability:
• Support Test Driven Development (TDD)
• Promote putting the testing tools into the hands of the Developers during the development life cycle, do not test at the end it’s “Too Late"
o Proven by
• Believe testing should begin as soon as development
• Functional (Conformance) Testing alone will not ensure Interoperability with External Partners
• Support a focus towards testing Specifications, and ensuring forwards and backwards compatibility
• Promote Gateway-to-Gateway communications