At a time when more and more patient care organizations across the U.S. are taking on financial risk, in a variety of forms—from developing accountable care organizations through the federal Medicare program or in partnership with private health insurers, or signing bundled payment- or population health-based contracts of any of a number of types—IT strategy and implementation are lagging behind corporate strategy.
Of course, even the corporate strategy itself is still a bit hazy at many U.S. patient care organizations. “Starting at 50,000 feet, there’s a need for conceptual readiness, for understanding who you are as an entity, and what your relationships are in your defined market space,” in order to take on risk, says Bob Schwyn, a Columbus, Oh.-based director in The Chartis Group, a Chicago-based consulting firm. “So if I’m in an organization in a market that’s starting to take on more and more risk,” Schwyn says, “the question becomes, how prepared am I as an organization to meet a growing level of risk in the value-based world? Do I have the operational infrastructure? The relationships I need to cover a population? How will I establish those relationships? Do I have the technology infrastructure to support that?” The reality, he says, is that “The IT industry right now is not where we need to be to support higher levels of risk.” The electronic health record (EHR) infrastructures have largely been created, he notes; the challenge now, he says, is building the first platforms for data analytics, care management, and so on, inevitably in an iterative fashion, given the demands coming from payers and the market environment.
“One foot in the boat” IT facilitation
Part of the fundamental challenge, say those helping to lay the foundations for accountable care and population health, is the need for patient care organization leaders to strategize forward, with the proverbial “one foot in the boat and one on the shore,” or deck, meaning, the need to continue leverage information systems to support fee-for-service-driven operations as well as the emerging risk-based operations. The reality, says Jeffery Spight, president of the White Plains, N.Y.-based Collaborative Health Systems consulting group, is that one doesn’t actually need to boil the ocean to make some needed adjustments to align information systems better with needed risk-based contracting processes. “There’s got to be a process that says, Mary Jane just showed up in the hospital tonight,” and here is an alert. Among the capabilities needed, he says, are patient registries and real-time lab value alerts. “It’s about collectively harnessing as much valuable information as possible to help physicians do the right thing.”
At the same time, Spight says, even though physicians in practice want to do the right thing, “Primary care isn’t often set up well in terms of information systems. Still, it doesn’t take Star Wars technology to do this right. I’ve worked with health systems in Singapore, the UK, Australia, Europe, and you see so many systems. And they did this well before there were EHRs and CCDs and alerts. They did this well. When Mary Jane went to the hospital, she knew she had to call someone about it. So a lot of people have thought that this would be about IT and financial incentives; but at the end of the day, this is really about cultural change,” he says.
Looking at the shifting landscape, Spight goes on to say, “I can tell you that the departure from fee-for-service has reached the point where I don’t think there’s a way back now. When you look at all the accountable care programs and related programs being sponsored by CMS [the federal Centers for Medicare & Medicaid Services], there are 8-9 million patients being cared for” under federal ACO contracts. “And as much as bundled-payment contracts have their role, this is the big bet. We have about $60 billion in all the Medicare ACO programs all together, so this really is the big bet. And what CMS has done is to put out lots of options to find a business model that works.” Further, he says, “It’s hard to administer one business model, let alone a dozen. But in the Next Generation ACO program”—whose details were announced in January—“you see about a dozen possible permutations; there are three tracks within MSSP [the Medicare Shared Savings Program], but with many options within those tracks. I see them at CMS creating a lot of different options to help us make it work.”
Given all this, Spight says that particularly in the Pioneer ACO, “Inevitably, in working with big agencies like CMS, there are growing pains, and not everything works. But the area in which we’ve seen some real differences” in the newer models of ACOs, particularly the Next Generation ACO program, “is in their willingness to accept comments, suggestions, and come out with new options. Now, we’re always going to see a lot of areas where we’re going to have challenges. But if you layer in the changes under the MACRA [Medicare Access and CHIP Reauthorization Act of 2015] bill, you now have concrete places that providers have to get to over time.”
All those interviewed for this article agree that having to operate information systems to simultaneously support fee-for-service and risk-based care delivery and payment systems, and the need to change culture, are among the core challenges right now. In addition, there is an entire range of IT operational issues that CIOs whose organizations are moving into risk are facing. Says Bill Russell, CIO at St. Joseph Health, an Orange, Calif.-based, 16-hospital health system, “As you take on risk, you’re typically delivering care across a network, and the network is not necessarily all internal to your system. So how do you manage quality, outcomes, access, across a network? So you have to start building out capabilities to look at the data outside of your silos.”
St. Joseph Health is participating in the Medicare Shared Savings Program for ACOs (MSSP). In that context, Russell says, “We’re leaving an EMR world to deliver on risk contracts across our network—and it’s like working with 100 EMRs. And you have to create a layer on top of your EMRs to build analytics capabilities, and also engagement platforms to interact with people for the 300-some-odd days when they’re not in front of a doctor.” That means facilitating video visits, physician-patient messaging, analytics for physicians (such as via dashboards), and a whole range of such capabilities, he emphasizes.
The Chartis Group’s Schwyn says he believes that inevitably, those farther along on the risk-contracting journey will provide guidance, directly or by example, to those earlier on their journey. “It’s interesting,” he says. “We’re starting to see a bit of a trend and we expect it to continue in the next two years, and that is that those organizations doing this better than others, may be geographically located near organizations that may be struggling with all this. And so we’re seeing affiliations across organizations to share knowledge. And the organization doing it well is saying, hey, maybe we can broaden our market profile here. And the organization needing the help is approaching the other organization. We’re actually working with a number of systems in a couple of different states, on collaborative work like this. So I think it’s going to be a lot more of that; I think those organizations will try to affiliate or align in some way, to try to leverage those resources.”
Also inevitably, CIOs and other healthcare IT leaders are having to put some pressure on their vendors to help facilitate interoperability in order get their disparate information systems being leveraged for accountable care and population health to work together successfully. “The vendors are getting pressure from their customers to make this work,” Rauschuber says. “As a whole, we’re starting to make progress, but it’s still baby steps. And we need to keep expressing our interests and needs; for the good of population health and care management, we have to pressure our vendors to do that.”