Here's a task for a CIO: Convince multiple groups with no history of cooperation to share data, overcome massively disparate systems, launch a big data analytics operation and, for an added degree of difficulty, meet a government imposed deadline.
That's the reality facing IT managers and other executives establishing accountable care organizations. The ACO, conceived under the Affordable Care Act, has become an important focus of healthcare reform, as they aim to reduce skyrocketing healthcare costs while boosting care quality.
ACOs Have 'Three Years to Figure It Out'
More than 250 ACOs have launched nationwide since the Department of Health and Human Services (HHS) set the ground rules for their creation in late 2011. The Centers for Medicare and Medicaid Services (CMS), a part of HHS, administers the government's ACO initiative and approves organizations seeking ACO status.
Private payers and large employers also sponsor ACOs separately from the government effort, driving the total number of ACOs to 428, according to Leavitt Partners, a healthcare research company in Salt Lake City.
Key ACO functions include coordinating patient care and improving the health of particular patient populations—particularly those with, or at risk for, chronic diseases such as diabetes. That's where IT comes in. Coordinated care calls for ACO members to share patient data—and tracking population health becomes a big data analytics job.
ACO managers say their organizations require four main technology components: Electronic health records (EHRs), health information exchange (HIE), data warehousing/analytics and patient portals. "You need a strategy around each one of those," says Chuck Podesta, senior vice president and CIO at Fletcher Allen Health Care, an academic medical center based in Burlington, Vt.
Podesta is helping create the IT foundation for OneCare Vermont, a statewide ACO. OneCare Vermont encompasses 13 hospitals, including Fletcher Allen, and 58 independent practices. Podesta said the plan is to get the ACOs technology aspects nailed down this calendar year.
That's a fairly rapid roll out, given that OneCare Vermont launched with CMS approval in January. But the ACO finds itself on a tight schedule: The group needs to hit CMS cost savings targets by 2016 to avoid a financial penalty.
"We have three years to figure it out," Podesta points out. It may be even less, too—Podesta believes an at-risk commercial insurance shared savings program may be in the offing prior to 2016.
Challenge No. 1: Universal EHR Adoption
The clock is ticking for OneCare Vermont and other ACOs. Organizations operating under the CMS Medicare Shared Savings Program will be rewarded if they cut costs while meeting 33 quality standards. An ACO that keep costs below a CMS-established benchmark gets to share a portion of that savings among its participants.
On the flip side, ACOs that see costs rise above that threshold are on the hook for shared losses. When the risk of loss actually kicks in depends on an ACO's arrangement with CMS. Under one model, ACOs can avoid shared losses for their first three years in the program. But after the initial three-year term, ACOs must make the numbers work or pay the price. The urgency is greater still for ACOs pursuing the CMS alternative shared-savings model, also known as the Pioneer ACO Model: Participants can share a bigger cut of the savings, but the risk factor appears in the initial term.
IT stands to play a pivotal role as ACOs endeavor to trim costs, improve patient care and qualify for shared savings or other financial incentives. An EHR is one foundational piece of technology ACOs need—"Everybody's got to have one," Podesta says—since achieving these goals is a matter of effectively sharing clinical information.
Podesta says the EHR adoption rate among Vermont's medical practices exceeds 70 percent. The ACO will have to get paper-record participants on to some sort of EHR, perhaps a cloud-based system, he notes. In the meantime, data may be abstracted from paper medical records for ACO use.
In Texas, the Baylor Quality Alliance, an ACO owned by the Baylor Health Care System, requires participants to adopt EHRs. EHR use is widespread: More than 1,800 participating physicians use EHRs compared to 170 doctors who are holding out, notes BQA President Dr. Carl Couch.
"It's our goal that everyone have an EHR, and we will push the stragglers who don't have an EHR to get one adopted by next year," Couch says.
EHRs may be one of the easier technology hurdles for ACOs, given expanding use across the country. A study published earlier this year in the Annals of Family Medicine reported that EHR adoption doubled among family physicians between 2005 to 2011. The study pegged the 2011 adoption rate among family doctors at 68 percent, suggesting that EHR penetration could surpass 80 percent in 2013.
Challenge No. 2: HIE Implementation and EHR Interoperability
Now for the bad news: Providers have adopted a wide variety of EHR systems, creating integration challenges for ACOs. Independent physicians working with BQA, for example, use 46 different EHR systems, Couch notes. (The situation with employed physicians is more straightforward. Doctors with Baylor University Health Systems' medical group, HealthTexas Provider Network, all use a single EHR, GE Healthcare's Centricity.)
For BQA and other ACOs, a health information exchange provides one way around the problem of incompatible EHRs, serving as an intermediary among EHR systems, providing bi-directional communication. "To wire together all those EHRs, the only solution we have been able to identify right now is an HIE," Couch says.
BQA is now deploying an exchange based on Covisint health data exchange technology. Couch says "the connection process is going on right now" and the ACO aims to connect the majority of the EHRs by December 2013.
Podesta estimates that OneCare Vermont will need to integrate EHRs from 15 to 20 different vendors. The ACO is now working with Vermont Information Technology Leaders, which operates the statewide Vermont Health Information Exchange. Podesta says a sizable portion of the ACO network is already hooked to the HIE, adding that OneCare Vermont is working with VITL to get the rest of the ACO's participants connected.
Dr. Gary Wainer, president of the Chicago Health System ACO, says the organization is exploring HIEs. He noted that some EHR vendors asks for large sums—ranging from $20,000 to $30,000—to build interfaces between their systems and the ACO's ICLOPS registry, a clinical database.
"We recognize that [HIE] is probably the solution," Wainer says, rather than trying to make one-on-one connectivity happen between multiple EHRs and the ACO's registry.
Challenge No. 3: Healthcare Big Data Analytics
ACOs will acquire large volumes of patient data as they develop. The real trick is to turn that data into information that can help providers improve individual care plans and boost the health of specific patient populations. Data warehouses and associated analytics tools are expected to contribute here.
Digital health records and data exchanges will help populate the data warehouses. HIEs will collect clinical data from EHR systems that can then be fed into big data analytics systems. CMS represents another important source of data, as the agency will provide Medicare claims data to the shared-savings focused ACOs.
Podesta said OneCare Vermont plans to combine HIE and CMS data in its IBM Netezza data warehouse. The ACO received its claims data from CMS in May and is now in the process of moving the data into the warehouse. The organization will use IBM Cognos business intelligence tools to analyze the data.
BQA, for its part, purchased Humedica's MinedShare population analytics platform. Crouch says the ACO is populating that system with data from several sources: The employed physicians' EHR, employed physicians' billing data, payer claims data, hospital inpatient EHRs and independent physicians' EHRs. For the latter group, the ACO will extract a more limited set of information from the EHRs and bring that data to the analytics platform over the HIE.
ACOs will use analytics tools to identify at-risk patients, identify health trends across a patient population and benchmark care programs. The objective is to acquire insights that can help shape treatment programs and establish best practices.
As they build in-house warehouses, ACOs also contribute data to regional and national resources that will let the organizations tap into a larger data set.
OneCare Vermont, for example, is moving its data to the Northern New England Accountable Care Collaborative, which aims to combine data from participating health systems in Maine, New Hampshire and Vermont.
Podesta says those systems will be able to access each other's de-identified patient data. Instead of deriving best practices based on an analysis of 5,000 diabetes patients, for example, an ACO would be able to draw conclusions from a much larger group, he explains.
Similarly, BQA plans to work with Anceta's data warehouse. Anceta, a subsidiary of the American Medical Group Association, maintains a warehouse with data on more than 25 million patients. "We'll contribute to that and we'll, in turn, benchmark our care against a huge universe of patients," Couch says.
Challenge No. 4: Patient Portals and Care Management
ACOs aim to increase patient engagement, and patient portals are one method to boost communication between patients and providers. Portals offer features such as secure messaging, the capability to schedule appointments and access to test and lab results.
The portal component tends to be the last of the four technology pillars that ACOs pursue. Couch says BQA plans to pursue a patient portal, following its work on EHRs, HIE and analytics. HealthTexas already employs a patient portal, but, he notes, the ACO would need portal technology with the ability to cover the entire organization. BQA has not yet defined the solution.
Fletcher Allen, for its part, uses Epic Systems EHR software and its MyChart patient portal, which the medical center has branded MyHealthOnline. Podesta says the ACO will look to deploy a more generic portal ACO-wide but adds that no decision has been made on what product to use.
Care management is another ACO-related technology that seeks to improve communication. Chicago Health System ACO in May adopted Care Team Connect care management software, which links hospitals, providers, family members and patients. The system lets ACOs share a patient care plan among those groups.
Wainer anticipates that, over time, acute care and post-acute care facilities, physicians and case managers will be able to view—and have input into—care plans via Care Team Connect. (The Chicago Health System ACO is part of Vanguard Health Systems, Chicago Market, a multi-hospital system.) Care Team Connect CEO Ben Albert says ACOs "need to engage the various communities."
Dr. Robert Wah, global chief medical officer for Computer Science Corp. (CSC), says ACOs must deal with the cultural challenge of bringing together entities that don't naturally collaborate.
Such a task isn't strictly an IT issue, but Wah says technology can play a role in care coordination. "There's a need for a digital solution. Most people don't believe you can do this on paper. You can't get information in a timely fashion, and you can't move it around in an easy way."