The BAE Company is looking forward to supporting CMS and the grantees with their respective project management and evaluation needs.  To inquire about our availability and service offerings, please contact us at 510.285.9069 or carladenise@thebaecompany.com.

Second, care coordination will be another core function of ACOs, as the CMS fact sheet and a consensus report by the leaders of the ACO and medical home movements point out. Manual care coordination of care at this level is too cumbersome, difficult and expensive for ACOs to undertake. So a variety of health IT tools — including establishing registries and directories, care management software, and automated CRM — will be required to coordinate care effectively. Definitely a target area for Data Warehousing.

Third, the Medicare shared savings program will require 50 percent of primary care doctors participating in ACOs to be meaningful users of EHRs. Since that program starts in 2012, this means that would-be ACO participants will have to meet the stage 1 criteria for meaningful use in the near future, as well as provide some sort of analytics in stage 2 and 3. For example, besides advanced decision support, the rule’s care coordination goals may require providers to use predictive modeling of patient health risks, telemedicine, comparative effectiveness research, and the exchange of clinical summaries both within and outside the ACO during transitions of care. There are also a number of criteria relating to data exchange with Medicare patients, including treatment reminders and advice about managing one’s health. However, the cost of establishing an ACO can be cost prohibitive. The government estimates that the average ACO will spend $1.75 million to start up and operate for the first year.

And fourth, the shared savings program requires ACOs to report a wide range of quality data. According to Brian Ahler, a health IT executive at Mid-Columbia Medical Center in Dalles, Ore., and the government will update the online reporting tool that some providers use to supply data for the Physician Quality Reporting Initiative (PQRI) so that ACOs can use it, as well.

The regulations have other implications for Data Warehousing. For example, data privacy and security will have to be beefed up as health information exchange becomes commonplace. CMS believes that with enhanced cooperation among beneficiaries, hospitals, physicians, and other health care providers, ACOs will be an important new tool for giving Medicare beneficiaries the affordable, high-quality care and eliminate wasteful, ineffective, and poorly coordinated systems of care, with consequent costs that are proving unsustainable. This is where we can leverage the power of Data Warehousing, as the ACO’s are determining the appropriate care and cost models, we can pull from our industry best practices in the commercial space (Travelocity, HCA, state Tax) and others to deliver scalable, robust, secure technology,

The first step a provider system must take to accomplish these goals in an ACO environment is to establish a technology infrastructure that drives collaboration and creates visibility for measuring accountability and care improvement. An important consideration is the inclusion of a health information exchange (HIE) to power the secure exchange of health intelligence. An HIE will build an online collaboration community that enables every party involved in patient care — regardless of technology differences and brick-and-mortar boundaries — to create a longitudinal patient record, share clinical data and coordinate care in a timely fashion.

While many hospitals and physician practices today are implementing or upgrading existing electronic health records (EHRs) to capture meaningful use incentives under the American Recovery and Reinvestment Act (ARRA), those systems are only part of the overall IT infrastructure provider’s need. Care providers and healthcare organizations must ensure that these systems can “talk” to each other to fully capture patient data and foster collaborative care.

One approach to building a collaborative ACO infrastructure is to replace multiple existing systems in favor of a single information system, enabling ACO participants to use their existing systems to capture all the data for fulfilling ACO objectives. The HIE infrastructure must be sophisticated and adaptable enough to handle a wide variety of functionality, including:

• Integrate health IT systems across disparate applications and care settings
• Provide a unified view of the patient across institutions and encounters
• Exchange transition-of-care documentation using federally recognized standards
• Interact with registries and perform public health reporting
• Enable bidirectional electronic “conversations” among all members of a care team
• Plug in to other HIE infrastructures outside of the ACO network
• Aggregate data to create longitudinal health records for clinical use and to enable reporting on quality measures such as follow-up frequencies, readmission rates and preventative care
• Track a patient’s care across all settings for administrative decision-making and reimbursement management

With the HIE infrastructure in place, an ACO can then layer evidence-based decision support tools and actionable clinical analytics. Clinical decision support (CDS) gives providers access to real-time information to help determine what treatment options are most appropriate based on a patient’s history. CDS can compile data derived from the HIE, analyze it against evidence-based medicine and deliver actionable alerts that help improve quality of care. Setting up the right CDS tools is not only an important step in qualifying for meaningful-use requirements, but also in enabling a hospital or group of providers to function as an ACO.

Another critical capability for an ACO is ready access to analytics that enable the organization to aggregate, analyze and report on the vast amounts of data it collects on patients, and act on it to develop best clinical practices and enhance population health. The goal is to share what is learned with every member of the clinical team and other decision-makers. This will result in better clinical, financial and operational decisions, which will drive efficiencies across the ACO.

While most of the discussion to date has been on the regulatory and operational aspects of ACOs, the central reason for implementing them is better and more cost-efficient patient care. ACOs will change the way everyone approaches patient care, including the patient. Greater focus and effort will be required to guide and engage patients, and not just those with chronic conditions.

Building a successful ACO will take more than just following the requirements of the Affordable Care Act:

1. ACOs participating in the Shared Savings Program will have an option between two tracks, where an ACO can choose whether it does not want to assume any risk for losses (until the third year of the program) or it is ready to potentially share in losses.
2. ACOs will be paid by normal fee-for-service methodology and are eligible for bonus payments if costs are below a pre-set benchmark.
3. CMS will define the patient population by identifying those patients who in the last three years received their care from the providers in the ACO. Since an ACO will not know which Medicare patients they are being evaluated on for the shared savings program until the end of the performance year, CMS assumes that it will raise the level of care delivered to all their beneficiaries to ensure that it maximizes its potential shared savings.
4. At the beginning of each performance year, ACOs can request aggregated data and information on beneficiaries that would historically have been assigned to the ACO and, as a result have a likelihood of being assigned during that performance year.
5. Quality measures will be used to determine the ACOs shared savings level.
1. CMS included 65 quality measures in the proposed rule for performance year 1 but does not base shared savings on quality measures until year 2.
1. Measures are grouped into five domains: patient/caregiver experience (7 measures); care coordination (16 measures); patient safety (2 measures); preventive health (9 measures) and at-risk population /frail elderly health (31 measures)
6. Data sharing is a key component of ACO program. CMS is proposing to make certain data elements available to ACOs on a monthly and quarterly basis to ensure that they have the right information to improve quality care, improve the health of their beneficiary population and create system efficiencies. An ACO will receive aggregated metrics on the assigned beneficiary population.
1. ACOs will be data-intensive and IT will be a key component; ACOs will especially need to develop robust data access and analytic capabilities.
7. ACOs that include federally qualified health centers (FQHCs) and rural health clinics (RHCs) in their network can be eligible for a higher percentage of any shared savings for including these providers.
8. ACOs are required to establish a legal entity and a governing body with authority to execute its statutory functions.
9. ACOs must commit to the program for the full three years and CMS is proposing to hold a percentage of the ACOs’ shared savings to ensure that they fulfill their pledge
10. Providers need to prepare for the new environment whether or not ACOs become widespread and should begin to put into place the elements that will improve their business model, irrespective of ACOs.
1. Improve quality
2. Reduce costs
3. Craft a business model that can thrive under a low per capital utilization environment
4. Coordinate care with other providers and/or identify potential partners

In grappling our way towards a more effective and less costly healthcare system, tools for using data to make the right decisions are going to be increasingly important. Offering a broad spectrum of data warehousing, benchmarking, analysis and reporting tools will be of use to the many stakeholders in an accountable care setting. The critical success factor for ACOs will be their ability to obtain, analyze, and act on cost and utilization data. Critical decisions regarding primary care physician selection and management, risk score and financial management depend on obtaining and analyzing data generating within an ACO. For this they will need a robust, scalable, flexible data warehouse architecture.

About the author: Joyce Hunter, the President & CEO of Vulcan Enterprises serves as a senior consultant with The BAE Company. More information about Ms. Hunter and her background can be found at http://www.vulcanenterprises-llc.com/.

By Carladenise Armbrister Edwards, Ph.D., MS.Ed

This public commentary was written in response to the February 8, 2012 Brookings Institution Governance Studies report entitled “Health Information and Megachange” by Darrell West and Allan Friedman.  As referenced here http://www.ihealthbeat.org/articles/2012/2/9/report-finds-variability-in-effectiveness-of-state-health-data-exchanges.aspx

Compliments to the Authors

Before I share my thoughts on the article by West and Friedman titled “Health Information Exchange and Megachange”, I want to compliment the authors and the Brookings Institution.  I absolutely love the theme of this article and I truly support the authors’ attempt to bring clarity to a very complicated topic that has huge implications for the health information exchange movement that began even prior to President Bush’s executive order in 2004.  The authors have done a fine job of identifying key issues related to driving policy change and they have gathered insight from some of the most well-informed and influential HIE leaders, including my friends and dedicated soldiers in the movement – Marc Overhage, Janet Marchibroda, Jennifer Covich Bordenick, Mark Frisse, Micky Tripathi and others.  Each of them helped drive home the point made by the authors that megachange is complex and requires significant consensus building, financial support, and political will.

The distinctions made between each state on the megachange color wheels displayed throughout the article were very insightful and arguably accurate in that each of the states started in a different place and each state has landed in a different place.  Time will tell what the final outcome will be for each state when the 2014 alarm sounds, but based on this report it does not look good.

Finally, the authors hit the nail on the head by re-iterating the fact that dominant players, governance, and the degree of consensus are key drivers in implementing HIE at the state level.  I do not disagree with the conclusions made in this regard at all; however, I do contend that full implementation of HIE will continue to experience stagnation and failure, if we continue to focus on the micro-level issues such as the players or leadership’s capabilities, participatory governance, and agreement on issues like financing and privacy and security.  The major barrier to successfully achieving the megachange is the actual implementation strategy, and not the individuals or entities responsible for implementing the strategy and their willingness to agree on complex issues.

Observations

After leaving my post at Cal eConnect, I sat still for several months to reflect on my experience and the challenges of running a state level HIE.  I recently started documenting what I think are valuable lessons learned that may benefit my successor and peers in similar posts across the nation.  I shared my first commentary with JHIM earlier this week. It is entitled “Stop Ignoring the Consumer: Consumer Involvement in HIE Governance is Key to Transforming Health Care.”  The Brookings article did not speak to the need for consumer engagement, but I believe it is a key HIE governance issue that I would love to discuss further and to get insight and feedback on as it is central to successfully implementing sustainable HIE.

The second issue that needs to be addressed related to the challenges of HIE implementation is the nature or structure of the current governance models. The current models do not adhere to any of our basic tenets or principles of organizational development, business management, non-profit governance, performance management, or behavioral and environmental change as taught by the experts we all know and love like John Piescek, Jim Collins, John Kotter, Peter Drucker, Urie Bronfenbrenner, and so on. You all know these experts better than I do and you probably have even had dinner with many of my icons.  I simply know and love their work and believe their thoughts and methodology is important to these discussions.

So, within that context – please think about this. Each state has developed a governance structure for HIE that is based on the tenets outlined in ONC’s State Cooperative Agreements for HIE that require a governing board that is comprised of multiple competing entities who represent the existing health care delivery system and all of its problems.  These non-profit HIE Boards are then comprised of individuals who represent business ventures in health care that are NOT necessarily highly motivated to change the status quo, unless it has a positive impact on their business and bottom lines.  Many of them admittedly participate solely to ensure that the interest of their organizations and constituents are protected and not harmed by decisions made by the HIE. These boards are then given a non-profit socialist mission to make health care more affordable and accessible to all using health information technology that enables the sharing of the very information that the board members have been told to protect.   All of this is happening as part of a government mandate to be entrepreneurial and start a non-profit business with public funding that must be sustained with private dollars post implementation.  So, as my kids would say: “Seriously?”

So, here is the fundamental question: Is it really logical or possible for competing for-profit entities to start a non-profit business with government money and then agree to financially sustain the effort that adversely impacts their business when in all honesty, consumers who are the people we are trying to protect have no idea what the value of the entire endeavor is, and most of them
are probably unaware of how it ultimately impacts our mega-goals of (1) bending the unsustainable cost curve that governments and employers are experiencing and (2) improving the health and well-being of our nation so we can continue to compete in the global economy?

Proposed Solutions

Having many times been in the position of trying to herd cats, I am fairly certain that the above is not possible or logical. As stated so well on page 3 of the Brookings article, the war on poverty was torpedoed by the “win-lose nature of income redistribution as a policy goal, insufficient cooperation among the relevant federal agencies, lack of clarity in program vision, and the bureaucratic nature of federal management style.”  I believe that the war on unsustainable health care costs, suboptimal quality, and limited health care access is being torpedoed by the same perils.  So, what do we do?

1) MAKE A DECISION: Each state (or the federal government) has to make a decision – Do we want to radically transform our health care delivery and financing structure so that we can reduce government and employer spending and improve access to quality and affordable care for all?  Yes or No?  If Yes, then…..

2) COMMUNICATE BROADLY AND NONDISCRIMINATELY: Each state (or the federal government) needs to make the PUBLIC (especially consumers) aware that this is our Mega-goal and their support and cooperation is required to make it happen.
This is not an issue that simply impacts the health care industry or one that should be driven by the technology, health plan, and provider lobbyist.  Reforming the health care delivery system is an issue that impacts all Americans and everyone deserves the right to know the extent of the problem and how they can contribute to the solution.  We need a mass public awareness campaign that educates and informs ALL.

3) STAY IN YOUR LANE:  Each sector needs to design and develop their own HIE game plan and stay in their lane.  The current HIE governance model depends on the ability of individuals with limited knowledge or expertise in designing HIE solutions to make decisions on things that are often outside of their common understanding or experience.    This is not intended to insult or offend any of my friends who serve on HIE boards.  I respect them all for their contributions and willingness to participate in the collective game, but running a mission-driven, publicly funded non-profit is NOT the same or anywhere near the same as running a for-profit, publicly traded corporation or even a member-driven, well-funded association. Each entity at the HIE governance table, needs to step back and establish an HIE war room at their home base and focus on running that, so that their organization is contributing to forming a solution that is mutually beneficial as opposed to sitting at a table of adversaries where they are driving holes in the solutions that someone else comes up with.  Specifically,

1. The private sector needs to figure out how they will help the state or the nation achieve this Mega-goal while continuing to meet the expectations of their shareholders.  If they need to change their business models, then do it.  If they need to change the types of products and services they offer to the market place, then do it.  If they have to go out of one business and start an entirely new business, then do that.  The private sector can still make money, but just not at the nation’s expense.
2. The government needs to decide if health information exchange is going to be a private venture (and then let the private entities figure it out) or a public utility (and then create the policies, regulations, and funding vehicles necessary to implement and maintain). The money that has been distributed to the states for the development of 54 disparate HIE systems could be used to develop 54 co-existing and aligned public utilities that will ensure the private and secure exchange of health information is possible, economical, and regulated.
3. The consumers need to hold the private sector and the government accountable for achieving the Mega-goal by voting with their pocketbooks!  Don’t purchase products or services from vendors who are not committed to the goal. Consumers have done this to drive environmental change, why not drive change in health care? For example, if the pharmacy and the physician refuse to do e-prescribing – find one that will.  If the EMR vendor refuses to create an interface to the PHR that enables you, as a physician to effectively communicate with your patients, then don’t purchase that EMR.  I know we can drive this change if all parties are better informed and fully educated on the issue and understand the megachange we are seeking to achieve.
4. The HIEs or RHIOs (formerly known as CHINs) should re-think the focus on leadership and name changes and that they focus on administrative re-organization and replacing the governance model with one that is capable of managing to the performance outcomes that are directly aligned with the megachange we are ALL trying to achieve. They need to create short term goals and a longer term vision that stays focused on the War and the steps required to end the War!  I believe all public servants should be in the business of writing themselves out of business by focusing on solving the problem at hand and then moving on.

I believe these public-private partnerships called HIEs could become a formidable force that demonstrates to the world our capacity as Americans to identify a complex problem and solve it.  Americans have successfully driven change in the past and I am confident we can drive this change into the future!  As a nation, we have faced many institutional challenges and somehow we have managed to tackle them.  But it was not done out of context nor single handedly by the industry that created the problem in the first place. Megachange requires a behavioral, environmental, structural, and policy context (as alluded to by the authors on page 2) and a MEGA-GOAL. It is critically important to maintain that context and create a Mega-goal and empower and incent the leaders in each contextual situation to take positive and affirmative actions that will ensure the change will actually take place and
the goal is achieved!

I could go on, but will stop here, as this is already more than I wanted to write and more than any real important person has time to read. (SMILE!)  I started this commentary with the intentions of thanking the authors for their efforts to explain the challenges of HIE Implementation and Megachange (which really needs to be separated from how the HBEs are being implemented) and to offer my solutions, in the event others want to continue this dialogue.  I look forward to any opportunity to offer additional perspectives on HIE implementation, financing and sustainability, consumer engagement, politics, as well as the relationship
between HIE and the Health Benefit or Insurance Exchanges.   As someone who has been more than intimately involved in the advancement of electronic health information exchange and driving organizational change through strategic planning, business development, and the adoption of technological enhancements for over 15 years, I have gained “a little bit” of knowledge and I am always looking for the opportunity to share.

I welcome your feedback and an opportunity to work with other change agents on this very important issue.  I have been a solid follower of The Brookings Institution and have benefited greatly from the Institutes scholarly work and incredible social consciousness.  I am honored to have the opportunity to respond and participate in the dialogue.

Please contact me directly or share your comments on my blog:

Carladenise Armbrister Edwards

The BAE Company, LLC

carladenise@thebaecompany.com

510.285.9069 office

850.445.1561 mobile

http://www.thebaecompany.com/blog/

http://www.linkedin.com/pub/carladenise-edwards/4/3b2/957

The Advanced Payment model application is NOT the Shared Savings Program application.
Organizations that are interested in participating in the Shared Savings program must complete a Shared Savings Program application.

More information and FAQs can be found by clicking and downloading the PDF.
The BAE Company Summary_CMS Forum_Advanced Payment Model 010512.pdf

Benefits and Challenges of Safety Net Participation in ACOs

We would like to extend a special thank you to HealthCare IT Connect (meeting organizers),  Kevin Kearns (President and CEO, Health Choice Network), and the summit attendees for participating in the first public dialogue about the role of the safety net in the formation of ACOs. 

For more information about how The BAE Company can help your organization develop a strategic and operational plan that will enable you to address the impact of PPACA and ACOs on your health care delivery system, post a comment or contact:

Carladenise A. Edwards
510.285.9069 office
850.445.1561  mobile
carladenise@thebaecompany.com

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