HOOK­ING UP AN ACO

EX­PERTS OUT­LINE IT IN­FRA­STRUC­TURE OF AN AC­COUNT­ABLE CARE OR­GA­NI­ZA­TION

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In­ter­nal sys­tems will need to col­lect, share, an­a­lyze and re­port clin­i­cal and fi­nan­cial data

Dr. Ed­ward Gold gets a re­minder by com­puter when a pa­tient missed a needed test or clinic visit. But that in­for­ma­tion stops when his pa­tients visit a hospi­tal or nurs­ing home. Com­put­ers at Gold’s clinic can­not talk to those on the out­side. Not yet.

Con­nect­ing Old Hook Med­i­cal As­so­ciates in Emer­son, N.J., where Gold prac­tices, to other in­de­pen­dent physi­cian groups and Hack­en­sack (N.J.) Univer­sity Med­i­cal Cen­ter has be­come a high pri­or­ity as the doc­tors and hospi­tal seek se­lec­tion as a Medi­care ac­count- able care or­ga­ni­za­tion.

“That’s the hard­est thing to ac­com­plish,” Gold said of the ef­fort to link the group’s di­verse in­for­ma­tion tech­nol­ogy so that pa­tients’ med­i­cal his­tory can be an­a­lyzed and shared among care­givers. “You can have case man­agers and you can have ed­u­ca­tion, but the in­for­ma­tion’s got to be co­or­di­nated,” said Gold, vice pres­i­dent and chief med­i­cal of­fi­cer for the Hack­en­sack ACO. “It’s re­ally not worth much with­out the in­for­ma­tion.”

Fed­eral health pol­icy has given new ur­gency to ef­forts by clin­ics and hos­pi­tals to use IT to more closely co­or­di­nate med­i­cal care. The CMS awarded $2.5 bil­lion last year of about $27 bil­lion to pro­mote health IT (Jan. 23, p. 10). And Medi­care re­cently be­gan to name net­works of doc­tors and hos­pi­tals as ac­count­able care or­ga­ni­za­tions, which are el­i­gi­ble for fi­nan­cial in­cen­tives to boost qual­ity and curb health­care costs. The CMS re­quires ACOS to re­port use of elec­tronic health records among pri­mary-care doc­tors as one per­for­mance mea­sure tied to in­cen­tive pay­ments.

With EHR soft­ware to flag high-risk pa­tients, home mon­i­tor­ing for the chron­i­cally ill and other IT, doc­tors and hos­pi­tals can bet­ter man­age dis­eases and pre­vent costly and harm­ful com­pli­ca­tions, health­care ex­ec­u­tives say. And Medi­care and com­mer­cial health plans will de­mand bet­ter care co­or­di­na­tion, dis­ease man­age­ment and preven­tion ser­vices of ACOS un­der con­tracts that call for mea­sur­ing and re­ward­ing qual­ity and ef­fi­ciency.

But first, hos­pi­tals and clin­ics must find ways to patch yawn­ing tech­nol­ogy gaps across the in­dus­try, in­clud­ing pa­per records and a ba­bel of soft­ware.

Growth of ac­count­able care prompted the ehealth Ini­tia­tive to re­lease guide­lines for IT in­vest­ment nec­es­sary to sup­port the var­i­ous mod­els that providers, the gov­ern­ment and pri­vate pay­ers are con­ceiv­ing un­der that name. The Washington-based not-for-profit said in a Jan­uary re­port—de­vel­oped with com­ments from 100 in­di­vid­u­als and or­ga­ni­za­tions—that in­for­ma­tion tech­nol­ogy should be flex­i­ble, se­cure and able to sup­port care co­or­di­na­tion and data anal­y­sis.

Ja­son Gold­wa­ter, vice pres­i­dent of pro­grams and re­search for the ehealth Ini­tia­tive, said the re­port sought to avoid overly pre­scrip­tive rec­om­men­da­tions that would be­come ob­so­lete as tech­nol­ogy evolved.

In­for­ma­tion tech­nol­ogy should en­able care co­or­di­na­tion and col­lab­o­ra­tion and al­low for se­cure trans­fer of per­sonal health in­for­ma­tion, the re­port said. Other rec­om­men­da­tions in­cluded in­te­gra­tion of ev­i­dence-based clin­i­cal decision sup­port and the means to help pa­tients and care­givers to be in­formed and play a role in man­ag­ing their own med­i­cal care. Tech­nol­ogy should sup­port ef­forts to im­prove pa­tient safety, through quick feed­back, track­ing and pre­dic­tive mod­el­ing, and boost qual­ity for at-risk pop­u­la­tions, by ag­gre­gat­ing data, giv­ing pa­tients ac­cess to their own health records and home mon­i­tor­ing us­ing tele­health.

New pay­ment struc­tures will also re­quire billing and col­lec­tion tech­nol­ogy to sup­port fi­nan­cial anal­y­sis, ac­cord­ing to the re­port.

Those func­tions should sup­port data gath­er­ing, anal­y­sis and fi­nan­cial mod­el­ing and iden­tify op­por­tu­ni­ties for im­prove­ment.

Lee Mar­ley, vice pres­i­dent and chief in­for­ma­tion of­fi­cer for Pres­by­te­rian Health­care Ser­vices’ Cen­tral New Mex­ico ACO, said tech­nol­ogy in­vest­ments will en­able the eight-hospi­tal or­ga­ni­za­tion to stan­dard­ize med­i­cal care along clin­i­cal guide­lines and al­low for data anal­y­sis to sup­port clin­i­cal de­ci­sions. Roughly 70% of Pres­by­te­rian Health­care Ser­vices’ physi­cian clin­ics have adopted a uni­form EHR sys­tem, and its first hospi­tal will make the switch next year, she said.

The push from pay­ers for new pay­ment mod­els such as ac­count­able care has forced hos­pi­tals and clin­ics to ac­cel­er­ate and ex­pand tech­nol­ogy adop­tion.

Ban­ner Health ini­tially moved at a “mod­est pace” to ac­quire tech­nol­ogy that can an­a­lyze med­i­cal records for trends and give pa­tients ac­cess to per­sonal health in­for­ma­tion, said Dr. John Hens­ing, the sys­tem’s ex­ec­u­tive vice pres­i­dent and chief med­i­cal of­fi­cer.

That was be­fore the Phoenix-based sys­tem be­came one of the first Medi­care ACOS in Jan­uary. Ban­ner was among 32 net­works se­lected for the CMS In­no­va­tion Cen­ter’s Pioneer Model Pro­gram. “There has been an ac­cel­er­a­tion of in­ter­est,” Hens­ing said, since Ban­ner agreed to man­age the treat­ment and health­care costs for se­niors in Medi­care.

Ban­ner’s tech­nol­ogy and ex­pe­ri­ence leave the sys­tem pre­pared for ac­count­able care, he said, but more tech­nol­ogy in­vest­ment will be needed. The last of Ban­ner’s 22 hos­pi­tals in­stalled an EHR sys­tem last fall. By the end of the year, its of­fices should all have the tech­nol­ogy. But the sys­tem lacks the abil­ity to an­a­lyze pop­u­la­tion data.

In­de­pen­dent doc­tors in Ban­ner’s net­work op­er­ate us­ing a “mish­mash” of in­for­ma­tion sys­tems, Hens­ing said; some have no sys­tem at all. Of­fi­cials are cal­cu­lat­ing the in­vest­ment re­quired to en­sure all doc­tors have EHRS he said. For now, Ban­ner must find ways to col­lect per­for­mance data from di­verse in­for­ma­tion sys­tems or pa­per charts.

The over­all ef­fort to adopt new tech­nol­ogy and in­te­grate dis­parate sys­tems, is ex­pected to take two years.

In Mas­sachusetts, where the state has ex­panded health in­sur­ance cov­er­age un­der a 2006 law with a frame­work sim­i­lar to the Pa­tient Pro­tec­tion and Af­ford­able Care Act, one Bos­ton health sys­tem has com­mit­ted $100 mil­lion to­ward tech­nol­ogy since 2008, but also ex­pects more in­vest­ment will be re­quired to sup­port its ac­count­able care ef­forts.

Stew­ard Health Care Sys­tem has be­gun to eval­u­ate an up­grade for its tech­nol­ogy to iden­tify pa­tients who would ben­e­fit from in­ter­ven­tion to pre­vent com­pli­ca­tions or hospi­tal vis­its, said Dr. Mark Gi­rard, pres­i­dent of the Stew­ard Health Care Net­work and ex­ec­u­tive vice pres­i­dent of the sys­tem.

Gi­rard, who over­sees Stew­ard’s ac­count­able care ef­forts, said the sys­tem will re­quire more so­phis­ti­cated anal­y­sis of its pa­tients as a Medi­care Pioneer.

The sys­tem will seek to ex­pand its IT to cap­ture in­for­ma­tion from long-term set­tings such as nurs­ing homes, Gi­rard said. Stew­ard also is de­vel­op­ing por­tals to al­low pa­tients to ac­cess med­i­cal records and care­givers to com­mu­ni­cate in­for­ma­tion about pa­tients.

Spend­ing on in­for­ma­tion tech­nol­ogy in­creased at At­lanti­care as the Egg Har­bor Town­ship, N.j.-based health sys­tem pre­pared for a com­mer­cial ac­count­able care con­tract. Christopher Scanz­era, At­lanti­care’s vice pres­i­dent and chief in­for­ma­tion of­fi­cer, said the sys­tem re­cently bought soft­ware to an­a­lyze med­i­cal records and flag gaps in med­i­cal care. At­lanti­Care will rely on a re­gional health in­for­ma­tion ex­change to col­lect data from in­de­pen­dent doc­tors with mis­matched in­for­ma­tion sys­tems.

Hack­en­sack Univer­sity Med­i­cal Cen­ter will also con­nect its net­work through a re­gional health in­for­ma­tion ex­change. Ben­jamin Bor­donaro, chief tech­nol­ogy of­fi­cer for Hack­en­sack Univer­sity Med­i­cal Cen­ter, de­scribed its ACO as “neck deep” in an in­ven­tory of clin­ics’ in­for­ma­tion tech­nol­ogy—in­clud­ing some prac­tices with­out any.

“We will have to get them up to speed pretty quickly,” said Dr. Peter Gross, for­mer chief med­i­cal of­fi­cer for the hospi­tal who stepped down to over­see the ACO’S de­vel­op­ment.

In­de­pen­dent doc­tors who have al­ready in­vested in sys­tems are un­der­stand­ably un­will­ing to switch, Bor­donaro said. But some sys­tems may be out­dated and can­di­dates for an up­grade. A sin­gle sys­tem would be ideal but un­re­al­is­tic, even as the par­tic­i­pants strive to ful­fill the am­bi­tious goals of the ACO en­deavor. “That’s never go­ing to hap­pen,” he said. “It’s not a per­fect world.”

Dr. Ed­ward Gold of Old Hook Med­i­cal As­so­ciates says pa­tient in­for­ma­tion that can’t be shared among care­givers is use­less.

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