Wide Load: Puzzling Out the Place of the Diagnostic Image in the Emerging Healthcare Landscape | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Wide Load: Puzzling Out the Place of the Diagnostic Image in the Emerging Healthcare Landscape

November 16, 2017
by Mark Hagland
| Reprints
Healthcare IT leaders, industry experts and observers share their perspectives on integrating image exchange into the new healthcare
Click To View Gallery

For years now, the question of how to fully inte­grate the appropriate sharing of diagnostic imag­es into healthcare data exchange—including into the phenomenon of health information exchange (HIE) has been a vexing one for healthcare IT leaders. Industry experts and observers agree: there’s got to be a better way than burning CDs and handing those to patients to hand to the next clinician down in the line in the chain of care delivery. And of course, the burning of CDs has been predicated on the shift nearly two decades ago now to digitized diagnostic images. Before that, health­care was stuck in the world of physical films.

But the landscape has been changing steadily over time. To begin with, “We’ve made a great deal of prog­ress in the industry in the last couple of years, as we’ve talked about freeing up the data and unshackling the image of the data repository,” notes Rasu Shrestha, M.D., a practicing radiologist and the chief innovation officer at the 20-plus-hospital UPMC health system, based in Pittsburgh. “We created the VNA [vendor-neutral archive] to free images from PACS systems. And then we realized that wasn’t even good enough; we needed more of a cloud-based, enterprise-wide ca­pability, regardless of where the patient, the clinician or the radiologist might be, as those are the three main actors who need to leverage the image and image-re­lated content.”

Indeed, Shrestha says, “There’s been a real mind shift in the last three years, that it’s not just about capturing the image and making it available; what it is about really is—you capture it once, you store it once, you imme­diately cloud-enable it, and you then make it available multiple different times. And what that’s given rise to is a solution that really addresses some of the key chal­lenges we have with going digital generally, which is one of scalability. There’s been an increase in demand for im­ages, with a need to focus on workflow, so that we can make this scale and make sense. We’ve moved from film to filmless, to image archives, to the VNA. And we’ve said, OK, we’re going to focus on enterprise content management, and that inherently requires that it all be cloud-based.”

And, amid that broad set of changes, one question that has arisen, as U.S. healthcare has begun to shift from a volume-based payment paradigm to a value-based one, has been how to integrate the flow of di­agnostic images, and of radiological reports, into the flow of data moving back and forth among clinicians. HIE organizations have made some inroads in some communities and states; but the sheer digital weight of diagnostic imaging studies has made their sharing via HIE networks—and their storage as well—problematic. So what is the solution? Increasingly, some healthcare IT leaders, industry experts, and observers, are conclud­ing, it won’t mean moving images around at all, but rather, providing access in situ to secured repositories holding those images.

Solutions Hiding in Plain Sight?

Speaking of the ongoing challenge of ensuring that diagnostic images and radiological reports are acces­sible and available at the point of care, Joe Marion, principal of the Waukesha, Wis.-based Healthcare In­tegration Strategies consulting firm, says that “I have personal experience of that, so it’s a hot button for me. I think there are a couple of things that are begin­ning to gel in the industry,” he goes on to say, and the most important emerging trend is that of “server-side rendering.” In that regard, he says, “Visage [the Rich­mond, Victoria, Australia-based Visage Imaging] is a prime example” of a new wave of vendors offering the ability to provide access to diagnostic images without having to laboriously move them through online pipes. In the case of these vendors, “All the manipulation of the images is done on the server side, and all I need is an HTML 5-type web-based viewer, with all the in­formation staying at the server—from a security point of view, I’m not passing information, and I’m not risk­ing PHI, because I’m not moving anything anywhere or waiting for anything to be moved.”

Another company that’s moved in this new direction is the Dallas-based WhamTech, which uses a trademarked “smart data fabric” approach to index-based data virtual­ization, federation, and inte­gration. As WhamTech’s chief technology officer Gavin Rob­ertson notes, his firm’s technol­ogy combines aspects of data warehousing, federated adapt­ers, and advanced web search, allowing authorized end-users to find images and data, as given permission, and to pull those images and data out for specific purposes, thus obviating the need to move web-heavy images around in traditional ways.

Marion says that, as these newer technologies are ad­opted, “That is going to open up the opportunity for greater sharing of images, because as a patient, I could get access to my images without physically having to access a DICOM viewer, or someone creating a CD. It’s there, it’s in the cloud. And from an ownership point of view, if I have my exam done at Aurora, Aurora can con­tinue to store the information, and I don’t need to physi­cally get a copy of it.”

As Marion puts it, “There’s no logical reason that di­agnostic images couldn’t be pushed to a storage site that I control as a patient.” Indeed, he says, in that con­text, “One might consider the idea that Google got out of the game too early, and though Microsoft hasn’t achieved this with their HealthVault, it’s something that is achievable. So I think that it’s all about storage and about access to that storage,” he says, “really just giv­ing people access to images through linkages. I think that that’s what’s going to open up the ability to share images across entities, in conjunction with CommonWell and some of these other initiatives that allow access to data. Also, the XDS—cross-document-sharing, protocol, which has emerged as an extension of the IHE, Integrat­ing the Healthcare Enterprise—that is a data format” that will allow more extensive sharing of diagnostic im­ages in the next few years.

David Muntz, the former Principal Deputy National Co­ordinator for Health IT, who is now a consultant with the Dallas-based Starbridge Ad­visors, agrees with Marion. “I had that same experience with my mother a year-and-a-half ago,” Muntz reports. “My mother was being treated at a couple of different facilities within the same integrated health system, and she was required to carry CDs from one facility to another; and the CDs couldn’t be read from one to the other, even though they were under the same corporate par­ent.” For purposes of disclosure, he notes that he is on the board of WhamTech, but he notes more broadly that the key to all of this is that “You have to look at what really comprises a medical image. There are two things—one is the image itself, including its techno­logical provenance. Then there is the interpretation of that image or set of images. Those two things do not necessarily have to move together. Unfortunately, right now, the state of the nation is that we’re able to move the interpretation or the report a lot more easily than the image, and that’s really related to bandwidth.”

What’s more, Muntz continues, “The second chal­lenge is, do we have the appropriate monitors, to ac­tually see the relevant and pertinent data, and so the quality of the image, whether in a diagnostic or con­sultative context, is also an issue. So those are trouble­some issues. If I see what people are doing now to try to solve the problem, it’s really around trying to move the image, and I’m not sure that that’s really the best way to do things. There are technologies that will al­low the image to be accessed at the source, and that changes the definition of interfacing, to that of remote access. If you had a link, which is what a lot of people use, to get to an image at its source—that involves both pluses and minuses. The minus is that you’ve got to move the image, but the plus is that you can then view it where it is,” he says.

George Reynolds, M.D., who for years served as the CIO and CMIO of Children’s Hospital & Medical Center in Omaha, and who is now a principal in his own con­sulting firm, Reynolds Healthcare Advisors, agrees with Marion and Muntz that there are challenges inherent in attempting to use the mechanism of the traditional health information exchange as a vehicle for efficient diagnostic image-sharing, and that newer technolo­gies are needed. “I think the idea of a common image repository, whether organization-specific or HIE-gen­erated, remains to be seen,” he says. “I think Denver has worked on a common image repository at the HIE level. But these things are not inexpensive. It seems like a great idea, but it hasn’t caught fire at the HIE level, whereas it clearly is catching fire at the IDN level. The other part of the question is, what level of image access should be involved? If you’re an ED doc and you know a CT was done yesterday—and maybe some­times, even access to the interpretation is enough; whereas, for the surgeon or radiologist, seeing the im­age may be more important.”

Matthias Kochmann, M.D., a pediatrician practicing in Indianapolis, agrees. “From the informatics perspec­tive, you will have very large files when you’re working with diagnostic images, and there’s a question of the value—do I need to see hundreds of slices, as a physi­cian? And maybe if it’s easier, I might want to see chest x-rays instead. So size is a problem; and also the type of images involved. And also, even though all the ra­diologists are board-certified and trained—I work in a hospital where there’s no children’s ward, because we’re next to Riley Hospital for Children, which is next door— when we need to consult over an image, we send it into the cloud. The more complex and specific you get, the more the institutions want to see it themselves. For ex­ample, the hospitals related to Harvard will always de­mand to see the images themselves. So the size, the type of image, will both be significant factors. And from the IT perspective, there’s another problem, in terms of integrating it. It’s very easy to integrate text everywhere. But the data file of the image is tricky. And then the last issue is that if you only have the report, that’s often suf­ficient, in many cases.”

Still, there are times when accessing a specific image or set of images can be impor­tant, including for a referring physician. Kochmann notes that, “A couple of weeks ago, we had a young child who had food stuck in his esophagus. It was circular and looked like a coin; but could also have been a button battery. If it were a button battery, that would have posed a real emergency, because the metal would start to erode. So you could argue that when it comes to more complex pictures, like the CT, you only need to send 10 slices. In that case, it went to Riley Children’s Hospital, they put him into sur­gery, with the endoscope, they pulled it out, and it was a coin. But seeing the image directly as a pediatrician was important in the moment.”

So appropriate image access and availability continue to matter, those with clinical backgrounds agree, includ­ing George Reynolds. Image access is “already easy,” Reynolds says, “in that, if you have access to a system’s PACS [picture archiving and communications system], you can literally access images via a web browser, sitting in your jammies in your basement. And now, increasing­ly, you’ve got incredible leaps beginning to take place in terms of leveraging AI [artificial intelligence] in the PACS system, where they’re able to help the radiologist pre-interpret. In my mind, the bigger issue is getting all the images—whether radiology, cath lab, GI lab, etc., into a common repository, so that you can see the continuum of images, the way you expect to see the continuum of data. It really is increasingly a part of how you tell the patient story.”

HIEs Move Forward on Image Exchange

Meanwhile, despite the fact that some in healthcare are urging that the industry adopt newfangled technologies in order to create new options for accessing diagnostic images and reports, some traditional HIE organizations are making progress in making diagnostic images more available to clinicians. One statewide organization that is helping to lead forward one version of that scenario is the New York eHealth Collaborative (NYeC), which over­sees the operations of the Statewide Health Information Network of New York (SHIN-NY). The appropriate sharing of diagnostic images is indeed one element in the broad strategy that NYeC and SHIN-NY are pursuing, says Val­erie Grey, NYeC’s executive director. “Image exchange is happening in a lot of parts of New York state now,” Grey reports. “In the last couple of years, we have used public funding to get image exchange up and running in vari­ous parts of the state” where image exchange had not yet occurred. Meanwhile, she notes, “Some form of im­age exchange has been happening within the RHIOs [re­gional health information organizations] for eight years or so now. The Buffalo and Rochester RHIOs identified the need, found a vendor, and added this as a service within their HIE. In the past several years, more RHIOs have ad­opted the technology, and in the past two years, we’ve had an initiative to fund this technology. It’s a bolt-on to your standard architecture. So in six of the eight RHIOs, image exchange is live, and we’re working to make it pos­sible across the RHIOs and regions.”

In fact, about 500,000 imaging studies (CT, MR, x-ray, etc.) are moving through New York state’s RHIOs every month, while “Upstate, in broad numbers, about 60 im­aging providers—private radiology clinics and hospital imaging departments—are connecting their images,” Grey reports. “By February 2018, we expect that to be about 80,” she says, adding that, in terms of the volume of imaging studies flowing through the RHIOs, “We ex­pect that to rise into the millions, when the downstate sites are connected live.”

Grey explains that, right now, in the SHIN-NY, a par­ticipating primary care physician or radiologist can look at an image or a report, through the HIE. Also, another radiologist, because of the system the RHIOs in NYS have implemented, can grab an image and download it into a PACS. “We feel that’s a really big benefit, be­cause there’s no need to repeat an image,” Grey says. “In some ways, we’re doing both right now. Also, go­ing forward, working with the vendor that all the RHIOs use, to implement the RSNA standards, around XDSI and XCAI gateways.”

Things are actually moving forward in a number of states now in terms of HIEs and im­age exchange. “What we’ve seen in the last several years, and we’re seeing a lot of this in western Pennsylvania,” UPMC’s Shrestha says, “is that these private HIEs are prolif­erating. Public HIEs weren’t quite the right business mod­el. And we have CCHIE, Clini­cal Connect HIE here in west­ern Pennsylvania; we’ve got a dozen-plus institutions in the region. And the HIEs are saying, we want more than a continuity of care exchange; we want access to the imaging reports as well as to the images them­selves. The HIEs know this is important, and it’s impor­tant for patients moving across these different sites of care. And you want to do what’s in the best interest of the patients.

What Should CIOs and CMIOs Be Doing?

Meanwhile, regardless of the channels, networks, or tech­nologies involved, one thing is clear: sets of diagnostic images, as well as radiological reports, will increasingly come to be essential to the success of population health management and care management initiatives under risk-based contracts in U.S. healthcare.

Asked what the CIOs and CMIOs of patient care or­ganizations should be doing, Reynolds says that “You could tie yourself into knots anticipating new business arrangements; but the single most important thing I would be doing as a CIO or CMIO in this context, is making sure I have a robust governance structure guid­ing the development of whatever architecture I’m de­veloping, so it’s clear what will be accomplished. Is it view versus diagnostic quality? Where will the images go? I need a battle plan so that I know how to present the information to the clinicians in a way that meets their needs and tells the patient’s story. And what’s the ROI for this? It’s going to be situational. It depends on where you are in the marketplace. It would be great if you had a statewide repository, and paid a fee to have a study there or access it,” he adds, “but we’re a long way from that in today’s market.”

“CIOs and CMIOs need to be working hand in hand with their clinicians and radiologists, to really look at, and push the boundaries of security and workflow,” Shrestha says. “They need to be looking at not just unshackling that image from their PACS systems, but at enabling im­ages to be freely shared across institutions and orga­nizations, and also giving patients direct access to im­ages, through portals as well as through patient apps.” Meanwhile, he says of HIEs, that “They really need to be taking a stronger leap of faith, and move away from just exchanging CCDs [continuity of care documents] and discharge summaries, and look at leveraging the power of the cloud, to allow for one-click access to images. The technology has really moved forward in the last four to six years on this, and HIEs need to capitalize on those capabilities. I do think HIEs are moving forward. RSNA [the Oak Brook, Ill.-based Radiological Society of North America] has been very supportive, through the RSNA Image-Sharing Network, of this effort.”

Will the journey forward be a long, complex one? No doubt. But image exchange is getting more attention now, and deservedly so. And the next few years will be important ones in the evolution of that phenomenon.

 


The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


/article/value-based-care/wide-load-puzzling-out-place-diagnostic-image-emerging-healthcare-landscape
/blogs/mark-hagland/value-based-care/when-it-comes-big-debate-acos-what-big-enough-savings

When It Comes to The Big Debate on ACOs, What Is “Big Enough” Savings?

| Reprints
The back-and-forth interaction between CMS Administrator Seema Verma and the ACO community is unfolding at a key inflection point in the evolution of the MSSP program

Intense debates on every subject are constantly swirling in the healthcare policy sphere; that has always been the case. But one debate that is both impactful and being closely watched is the intensifying argument between the Centers for Medicare and Medicaid Services, particularly CMS Administrator Seema Verma, and some leader organizations in the accountable care organization (ACO) area.

At its base, the proposal on the part of CMS, as outlined in a proposed rule published in August, to push more ACOs into two-sided risk, is being pushed back against by many ACO leaders, particularly by their nationwide association, NAACOS (the Washington, D.C.-based National Association of ACOs). As Managing Editor Rajiv Leventhal noted in his report Dec. 5, CMS’s “core aim” is “to push these organizations into two-sided risk models—so that Medicare isn’t on the hook when ACOs overspend past their financial benchmarks—suggested to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years.”

As Leventhal noted, “One option, per CMS’ proposal, would be the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk. The second option would be the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program. But where CMS, in its proposals, truly clamped down was through two core recommendations that stakeholders took issue with: shortening the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years; and cutting potential shared savings in half, from 50 percent to 25 percent for one-sided risk ACOs. These proposals, if finalized, will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny.”

Clifton Gaus, Sc.D., NAACOS’s president and CEO, recently gave Leventhal an interview, and in that interview, he confirmed his association’s stance that the reduction of shared savings and the shortened time allowed in one-sided models are two of the biggest problems the group has with the proposal. Indeed, Gaus said in that interview that the reduction in potential shared savings “would be very devastating to the growth of new ACOs.”

In fact, Gaus said, in polling their members, NAACOS’s leaders asked them whether they would in theory join a federal ACO program knowing that, at least at first, they would be limited to 25 percent of shared savings at most; and, in fact, “the near universal response was no, they wouldn’t have joined the program,” Gaus said, adding that “The potential of 25 percent savings just isn’t enough to offset our investment costs of starting and operating the ACOs,” noting that ACOs have to obviously put up money to get going, and sometimes it’s very hard for medical group practice-dominant ACOs to buy IT systems, not to mention the whole clinical transformational aspect of ACOs where they are typically hiring nurse coordinators, and in some cases opening 24/7 call centers. “There is a real start-up and operational cost that’s involved, and [getting] 25 percent of the shared savings doesn’t return enough income to offset those,” he said.

Meanwhile, this morning, NAACOS issued a new press release focused on the value that the MSSP program has created for CMS. “In the latest data proving the financial benefits of accountable care organizations (ACOs), Medicare’s largest value-based care initiative – the Medicare Shared Savings Program – saved $859 million in 2016, an independent analysis published today shows,” the press release began. “Since 2013, the first full year of the program, ACOs have saved Medicare $2.66 billion, well above the $1.6 billion calculated by the Centers for Medicare and Medicaid Services (CMS).” What’s more, the press release reported, “After accounting for bonuses paid to ACOs for hitting spending and quality targets, the program, which accounts for 561 ACOs and 10.5 million patients nationwide, netted more than $660 million to the Medicare Trust Fund between 2013 and 2016, contrasting the net loss of $384 million CMS estimates.”

And the press release quoted NAACOS’s Gaus as stating that “These results are the latest data point in a growing body of evidence unequivocally proving ACOs’ value. ACOs are saving American taxpayers hundreds of millions of dollars at a time when it’s most needed.” Indeed,  he added, “Given the natural lag time in collecting and analyzing data and the well-established trend that ACOs need a few years to start demonstrating results, we are only seeing the beginning of the nation’s return on investment in accountable care. This data doesn’t even mention the quality benefits ACOs have generated, which have also been substantial.”

Further, the press release noted, “A sizable amount of recent data show ACOs are saving money: 472 Shared Savings ACOs generated gross savings of $1.1 billion and netted $314 million in savings to the Medicare Trust Fund last year; CMS’s August 17 proposed rule estimates the overall impact of ACOs, including ‘spillover effects’ on Medicare spending outside of the ACO program, lowered spending by $1.8–$4.2 billion in 2016 alone.”

So now we reach the rubber-meets-the-road place. Here’s the fundamental question: Do Seema Verma and her fellow CMS and HHS (Health and Human Services) senior officials truly understand the complexities involved in what they’re asking of provider leaders? Verma and her fellow federal healthcare officials are facing a kind of Scylla and Charybdis situation right now. On the one hand, as everyone knows, the Medicare actuaries have predicted that total U.S. healthcare spending will explode from $3.1 trillion annually (in 2014) to $5.4 trillion annually (by 2024), in the next several years, amounting to a 70-percent increase in less than a decade, and bringing the percentage of GDP spent on healthcare in this country from 17.4 percent in 2013 to 19.6 percent in 2024.

On the other hand, as Clifton Gaus and the NAACOS folks have pointed out, based on surveying their membership, patient care leaders are going to recoil at the over-intensification of change mandates coming out of CMS. That feeling is quite widespread. As one ACO CEO told me just two weeks ago, Seema Verma is deluded if she thinks that ramping up the downside-risk requirements in the Medicare Shared Savings Program is going to inspire more patient care leaders to join the MSSP program or renew their participation in it. And, as this morning’s press release notes, ACO community leaders are documenting real progress in capturing savings.

The million-dollar (or maybe, $1.1 trillion-dollar?) question is, is the broad level of savings that ACOs are netting for CMS, progress enough? Indeed, what is “enough”? And what is “fast enough”? Because Administrator Verma and her fellow senior federal healthcare officials seriously risk cratering the MSSP program, the core federal ACO program, if they push too hard on the downside-risk issue. On the other hand, if they don’t push hard enough, the progress made so far could simply be dwarfed, in the broader scheme of things, by the current acceleration of overall U.S. healthcare spending inflation.

So right now really does feel like an inflection point—but one without an obvious resolution. Only time—and the interactions of federal healthcare officials and providers—will tell.

 

 

More From Healthcare Informatics

/article/value-based-care/upmc-turbo-charging-quality-improvement-efforts-through-data-analytics

At UPMC, Turbo-Charging Quality Improvement Efforts through Data Analytics

December 11, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
At UPMC, Dr. Oscar Marroquin is leading a team of data analysts whose work is facilitating intensive efforts around readmissions

At a time when the leaders of patient care organizations are facing intensifying pressure to shift away from a dependence on volume-based payment and to plunge into value-based care delivery, some U.S. hospitals, medical groups, and health systems are helping to lead the way into a future of continuous clinical improvement and of clinical transformation. That topic—of organized continuous quality improvement—was the subject of the fourth-quarter 2018 Healthcare Informatics cover story. Numerous leaders of pioneering organizations were interviewed for their insights into the health system change focused-quality improvement movement that has been emerging across the U.S. healthcare system.

Among the leaders interviewed for that cover story was Oscar Marroquin, M.D., a practicing cardiologist and epidemiologist, who is helping to lead a team of clinical data experts at the vast, 40-hospital UPMC health system in Pittsburgh. Dr. Marroquin and his colleagues have been busy harnessing the power of creating and nurturing purpose-specific teams focused intensively on the management of data to power performance improvement, particularly in the clinical area. Marroquin’s team, of about 25 data specialists, was first created five years ago. Of those, half are IT- and infrastructure-focused, and, says Dr. Marroquin, “The rest are a team of folks dedicated to data consumption issues. So we have clinical analysts, data visualization specialists, and a team of data scientists who are applying the right tools and methods, spanning from traditional analytical techniques to advanced computational deep learning and everything in between. Our task is to use the clinical data, and derive insights”—and all 12 clinically focused data specialists report to him.

And that work—“allowing people to ask questions to generate opportunities”—has paid off handsomely. Among the advances has been the creation of a data model that predicts the chances of patients who are being discharged, being readmitted. The model, based on the retrospective analysis of one million discharges, is also helping case managers to more effectively prepare patients for discharge, specifically by ensuring that patients being discharged are promptly scheduled for follow-up visits with their primary care physicians. “If those patients are seen within 30 days of discharge,” he notes, “there’s a 50-percent reduction in their 30-day rate of readmission.” The program is now active in six UPMC hospitals.


Oscar Marroquin, M.D.

Below are excerpts from the interview for that cover story that Healthcare Informatics Editor-in-Chief Mark Hagland conducted with Dr. Marroquin this summer.

From your perspective, what does it really mean to be data-driven, in the pursuit of continuous quality improvement and clinical transformation?

From my perspective, I’m very passionate in that I feel that you really can’t do any of the things that doing in terms of moving towards value, without having a robust data infrastructure, a robust strategy on how to use data and analyze it, and without then deriving evidence for how you’re going to transform your organization. There are a lot of buzzwords involved in all of this, but the only way to get from a buzzword to a true action of transformation, is if it’s data-driven.

I’m a cardiologist by training and an epidemiologist; I still practice. Over the past five or so years, I’ve been asked to oversee how we’ll derive insights from clinical data in our system; in other words, this work is around anything related to big-data analytics, with those analytics being used to help our clinicians. In order to do that, we’ve had to do many different things, including more intelligently aggregating our data, and focusing on specific analytical purposes. They’ve been structured as databases for transactional systems, but not with the intent of improvement.

So we’ve spent a lot of time creating a purpose-built environment for analytics. That’s involved a lot of technical work, to create tables, what we call our consumable layers, for analytical purposes. And we’ve created a team whose only job is to do analytics. We’ve had folks in the past managing back-end databases, who have generated reports, but that doesn’t lead to a sustainable way of using data. And so we have a team that is dedicated to maintaining the warehouse and consuming the data.

With regard to the team of 25 data analysts, do all of them report to you?

The 12 who do data consumption report directly to me; the others have a dotted-line report to me. They sit on our infrastructure team within our IT Information Services Division. Both teams are part of the Clinical Analytics Team. Data analytics—Health Services Division. Integrated team. Two sides of the same coin.

When did these teams come together?

There have been different phases. The analytics program development started in 2012, and we learned a lot of lessons. A lot of the work early on had to be dedicated to technical issues—identifying data sources, etc. That was a pretty labor-intensive process. We really got enough aggregated data to use it consistently in 2015, so from 2015 on, we’ve had this structure of teams dedicated to doing this as I’ve described.

Can you share a few examples of key advances that your team has made so far?

When asked what our team does, I tell folks we do work at the higher level in three different buckets. The first bucket is the entry point for the majority of projects. Not everybody in the system necessarily knows which questions to ask.

We allow people to ask questions to generate opportunities. Off of that, two things will happen. One, hypotheses can be generated, and so we can do hypothesis testing, we can do comparative effectiveness studies, we can formal testing of hypotheses. Also, when insights get generated, one can say, oh boy, there’s a lot of heterogeneity in this population, why is one group more at risk? So we can identify who is at high risk of a condition, and who within the high-risk category is at high risk of developing specific conditions? And the third level or bucket, we apply machine learning and AI tools to develop models that allow us to do a variety of things, from more precise phenotyping of our populations; we can build predictive models to identify patients at various levels of risk. And we also use these models to do unsupervised learning, where we can start to generate hypotheses. So most people in this space love to talk about the latter part, the predictive modeling, and we have done a fair amount of work there, with things like identifying patients at highest risk of rehospitalization after 7 or 30 days of discharge, and we’re using that in our hospitals to guide clinicians. There are resources everywhere.

So we developed a model derived out of retrospective analysis of one million discharges, and we’ve prospectively verified that the model allows us to identify patients at the highest risk of readmission, so our case managers can help us identify plans to help those patients transition from hospitalization to post-acute care in a more effective way. And we see that if they’re seen within 30 days of discharge, there’s a 50-percent reduction in their 30-day hospitalization if they get in to see a clinician. So we make sure that the patient has an appointment made and is ready to see their doctor once they’re discharged, to address any issues.

When was that program put into place?

We spent a lot of last year validating the data. And then this year, we started rolling this out to our hospitals in a phased approach, so throughout 2018, we’ve been deploying this to our hospitals, and we’ve trained and educated different hospitals to use the model, and we’re actively following patients to measure the impact of the tool. And as an epidemiologist, I’m always cautious about declaring victory too soon. We’re seeing good trends, our smaller hospitals are seeing decreases in patients coming back early.

So you don’t have any metrics to share yet?

We have three hospitals, smaller ones we started the program with first, that different units, have shown that this program has had an impact. The numbers are still small enough that I have reservations about absolute certainty. But already, we’re using the program in 20 of our hospitals.

What would your advice be for CIOs, CMIOs, and other healthcare IT leaders, as they consider these kinds of initiatives?

If we all are serious about transforming the way we care for patients, we need to do it in a data-driven way. There has to be a philosophical belief and commitment to do that. Number two, as a result of the institutional commitment and philosophy, then there has to be a team that’s dedicated to this work. I don’t think this is achievable in an ad hoc way, when people just have time. And three, it’s not for the faint of heart; it takes time and effort, but if you have the philosophical belief and institutional commitment, it’s doable. If I say to myself, I don’t ever want to leave my house and get drenched because I wasn’t prepared for a storm, then I need to check the weather app before I leave my house. In medicine, we haven’t yet taken that approach, but the data and analytics are there to guide us in helping us to make decisions, and making it a part of the everyday decision-making process. And in the same way I use examples of rehospitalization prediction, we also do condition-specific predictive analytics, around patients with asthma, kidney disease, etc., so there’s a lot of work going on there. And the message I give clinicians is, there will be companies that say they don’t’ sell you the predictive models they’ve developed; but in our experience, the models have to be a part of an organic process that leads to the building of the models. Clinicians won’t feel alienated, disenfranchised, or threatened, if you bring them in and engage them from the beginning.

 


Related Insights For: Value-Based Care

/article/value-based-care/exclusive-naacos-president-foresees-shrinkage-accountable-care-movement

EXCLUSIVE: NAACOS President Foresees “Shrinkage in Accountable Care Movement” Pending MSSP Final Rule

December 5, 2018
by Rajiv Leventhal, Managing Editor
| Reprints
If CMS doesn’t scale back some of its proposed changes to the MSSP, the government’s largest value-based payment program will be significantly affected, says one ACO leader

When the Centers for Medicare & Medicaid Services (CMS) released its proposals to overhaul the federal Medicare Shared Savings Program (MSSP), it was expected that industry associations, along with the ACOs (accountable care organizations) themselves, would push back strongly.

After all, in the August proposed rule, CMS, which has the core aim to push these organizations into two-sided risk models—so that Medicare isn’t on the hook when ACOs overspend past their financial benchmarks—suggested to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years.

One option, per CMS’ proposal, would be the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk. The second option would be the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

But where CMS, in its proposals, truly clamped down was through two core recommendations that stakeholders took issue with: shortening the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years; and cutting potential shared savings in half, from 50 percent to 25 percent for one-sided risk ACOs. These proposals, if finalized, will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny.

One of the trade groups that has done much of the heavy lifting when it comes to pushing back on the government’s proposals, and offering evidence as to why ACOs need more time in one-sided risk models while being able to reap more of the shared savings, is NAACOS (the National Association of ACOs,) an association comprised of more than 360 ACOs across the U.S.

In a recent interview with Healthcare Informatics, Clif Gaus, president and CEO of NAACOS, confirmed that the reduction of shared savings and the shortened time allowed in one-sided models are two of the biggest problems the group has with the proposal. Specifically, Gaus says that the reduction in potential shared savings “would be very devastating to the growth of new ACOs.”

He explains that after polling NAACOS’ members, asking them if they would hypothetically apply to be an ACO knowing that at first, they would be limited to 25 percent of shared savings at most, “the near universal response was no, they wouldn’t have joined the program.” Gaus adds, “The potential of 25 percent savings just isn’t enough to offset our investment costs of starting and operating the ACOs,” noting that ACOs have to obviously put up money to get going, and sometimes it’s very hard for medical group practice-dominant ACOs to buy IT systems, not to mention the whole clinical transformational aspect of ACOs where they are typically hiring nurse coordinators, and in some cases opening 24/7 call centers.

“There is a real start-up and operational cost that’s involved, and [getting] 25 percent of the shared savings doesn’t return enough income to offset those,” he says.

Regarding the proposal to shorten the time in a one-sided risk model from the current six years to two years, Gaus points to CMS’ own data which shows that more experience in a federal ACO model drives more savings, but typically the first few years are not profitable for the ACO.

“We have many examples where an ACO has been in the program and was able to turn the corner by the fifth or sixth year,” he says. “Medicare has to have a long-term view of this. We are investing in a totally new redesign of the healthcare system, so give us time to learn how to transform that care into more efficient and higher-quality care. We are troubled by two years,” Gaus frankly admits. He believes that capping the time in a one-sided risk model at three to four years “is reasonable,” and is what many other associations have proposed.

Indeed, while NAACOS and other industry groups have made their arguments to CMS clear, the federal agency has so far taken a firm stance that upside risk-only ACOs have not been effective. A such, CMS seems to be fine with these ACOs leaving the MSSP— by far the largest federal ACO model, with 561 participants—if they are unwilling to take on more risk.

But Gaus believes that even though CMS did come out of the box with an “aggressive negative message” about one-sided ACOs, the agency has now moderated its views. To this end, a recent study from NAACOS and Dobson Davanzo & Associates, based on a different way of measuring financial success—by comparing actual costs over time in the ACO’s market as opposed to CMS’ method of calculating an initial risk-adjusted spending benchmark for each ACO based on its historical spending, without considering underlying market factors—revealed that MSSP ACOs generated gross savings of $1.84 billion for Medicare from 2013 to 2015, nearly double the $954 million estimated by CMS.

“The whole dialogue has changed,” says Gaus. “We have met with Seema and a number of her staff over the last two months, and the driving factor to this change in dialogue is that the 2017 data, from CMS’ benchmarks, turned the corner and showed that net-net the ACO program was saving Medicare money. You don’t see CMS coming out anymore arguing that the program is losing money,” he says.

What a Final Rule Might Look Like

Gaus acknowledges that a core challenge for CMS is being in the precarious position of pushing down too lightly in its regulations, which could result in the pace of change being too slow, or pushing down too hard, which could result in provider organizations fleeing value-based care initiatives.

“We know the government is wrestling with this issue, and so are we,” Gaus says. “In the crafting of our comments to CMS, as well as the comments from the AHA [American Hospital Association], AMA [American Medical Association], and others, we felt that the balance is the issue here, and there needs to be some movement toward the direction that CMS is pushing. We do respect their concerns, to a degree, but we just thought they were too aggressive in their speed to risk, or speed to remove an ACO from the program,” he says.

Gaus is hopeful that the final rule on the future of the MSSP—which he believes could come by the end of the year, but no later than the end of January—will reflect the industry’s concerns. “History says that this administration, like many others, does listen to input from stakeholders that the rule affects. I believe that they really do understand our positions,” he adds.

At the same time, NAACOS’ position is that the reduction in potential shared savings, as currently proposed, is a “total deal breaker,” and that there is no wiggle room for a number between 25 and 50 percent, Gaus asserts. He adds, “If they don’t go back to 50 percent, we will see a long-term significant shrinkage in the ACO movement and a significant emanation of accountable care.”

Importantly, Gaus also notes that ACO programs are voluntary in nature, a key consideration that he believes CMS often forgets. “Nobody has to be an ACO. [Providers] are making a bet of their capital, that they can invest that capital in cost containment, in care transformation, and [in return], they will get back in the shared savings more than they invested. It’s almost like buying stock—you made the investment and you hope the return is worth it,” he says.

Gaus says that he has told Verma in their many conversations that in many ways “we are at a crossroads, and we have to get the balance right, or we are going to see a denigration of what still remains the largest government value-based payment program.”


See more on Value-Based Care

betebet sohbet hattı betebet bahis siteleringsbahis