Healthcare Informatics

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Mobile EHRs: Full Speed Ahead?

Telehealth Blazes Trails Out West

Healthcare

Five Tips for ICD-10 Compliance

Informatics Volume 31, Number 5

July/August 2014

Healthcare IT Leadership, errship, V Vision ision & Strategy Strategy

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CONTENTS July/August 2014

COVER STORY 8

ACCOUNTABLE CARE: HIGH HURDLES

How are ACOs taking shape as healthcare leaders push their patient care organizations into the new healthcare? Six leaders who have undertaken the journey share success factors as well as challenges BY MARK HAGLAND

16 MOBILE EHR ADOPTION: FULL SPEED AHEAD? Does the rapid growth of consumer-based mobile health applications signal that clinical apps are ripe for tablets and smartphones? Here is the prognosis BY GABRIEL PERNA

DEPARTMENTS 4

INSIDE

6

EDITOR’S PAGE

28

A Beacon Partners consultant shares five tips that healthcare providers can use to implement ICD-10 in their organizations BY GABRIEL PERNA

30

TELEMEDICINE UPDATE

TELEHEALTH MAKES GAINS OUT WEST Why providers in California and Colorado are embracing the idea of incorporating virtual visits into their patient care BY DAVID RATHS

34

I.T. IN CARE TRANSITIONS What is the proper role of IT in improving transitions of care? One expert puts it this way: ‘Don’t let the perfect be the enemy of the good’ BY GABRIEL PERNA

36

PAYERS, PROVIDERS, AND DATA Can payers and providers transform healthcare by collaborating on data? A panel of healthcare leaders cites evidence that the industry is at least moving in that direction BY MARK HAGLAND

26

38

MEANINGFUL USE UPDATE TWO CIOS TALK MEANINGFUL USE STAGE 2 CIOs of two provider organizations that are early attesters of Stage 2 meaningful use expressed their thoughts about the process during a recent meeting of the Health IT Policy Committee. Here’s what they said

BY DAVID RATHS

EHR PERSPECTIVE I.T. JOURNEY TO STAGE 7 RECOGNITION How Cleveland-based MetroHealth achieved HIMSS Analytics Stage 7 Ambulatory EMR recognition, becoming one of the first safety-net health systems in the country to do so BY RAJIV LEVENTHAL

HIE PERSPECTIVE SUTTER HEALTH STEPS UP WITH DATA EXCHANGE How a leading California health system is broadening its data exchange efforts by implementing its own fully integrated HIE BY RAJIV LEVENTHAL

PAYER-PROVIDER PERSPECTIVE

23

ACO PERSPECTIVE M.D.-LED AND OTHER ACOS: A COMPARISON The first national survey of ACOs, released in June, found that physicians are playing a strong leadership role. Here are the key findings and implications for the evolution of ACOs BY MARK HAGLAND

CARE TRANSITIONS PERSPECTIVE

22

MOBILE HEALTH UPDATE BIG SAVINGS WITH mHEALTH AT ONE HOSPITAL The CIO of Jersey City Medical Center explains how a smartphone app has improved efficiency at his organization through better communication across the medical staff BY RAJIV LEVENTHAL

iHT2 HEALTH I.T. SUMMIT 20

ICD-10 PERSPECTIVE FIVE WAYS TO CAPITALIZE ON THE ICD-10 DELAY

40

CAREER PATHS INTERIM TALENT: A GROWING TREND With interim executives increasingly in demand, here are the elements of a fruitful assignment, both for the employer and the employee BY TIM TOLAN

Healthcare Informatics (ISSN 1050-9135) is published 8 times per year by Vendome Group, LLC, 216 East 45th Street, 6th Floor, New York, NY 10017. Periodicals postage paid at New York, NY and additional mailing offices. POSTMASTER: send address changes to HEALTHCARE INFORMATICS, P.O Box 2178, Skokie, IL 60076-7878. Subscriptions: For questions or correspondence about a subscription, phone 847-763-9291 or write to HEALTHCARE INFORMATICS, PO Box 2178, Skokie, IL 60076-7878. If you are changing your address, please enclose entire mailing label and allow 6 to 8 weeks for change. Subscription rate per year (U.S. Funds): U.S. $58.00; Canada/Mexico $82.00; all other countries $109.95 (includes air delivery). Single copy rate (U.S. Funds) except September and January: U.S. $8.00; Canada/Mexico $12.00; all other countries $15.00. September 100 and January Resource Guide: $50.00 (U.S. Funds) includes shipping/handling to all countries. Add state and local taxes as applicable. 2 July/August 2014 • www.healthcare-informatics.com

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EDITORIAL

INSIDE

EDITOR-IN-CHIEF Mark Hagland [email protected]

Accountable Care Update, Mobile EHRs, Telemedicine Gains

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hat progress has been made in the accountable care arena, and what are the remaining hurdles? In this month’s cover story on page 8, Editor-in-Chief Mark Hagland interviewed six leaders of patient care organizations that are participating in Medicare’s ACO program. The answers they provide shed light on critical success factors, challenges, and new opportunities as their organizations push forward into the new era of healthcare. At a time when burgeoning consumer-based mobile health applications are squarely in the healthcare innovation spotlight, can clinical apps for smartphones and tablets be far behind? To find out, Senior Editor Gabriel Perna gives his prognosis on whether the time of mobile EHRs adoption is at hand. His analysis appears on page 16. This issue provides a glimpse of two hot healthcare topics that will be discussed at the Health IT Summit, sponsored by the Institute for Health Technology Transformation (iHT2), which will take place in July in Denver. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through its parent company, Vendome Group LLC.) On page 20, Senior Contributing Editor David Raths reports on progress in telemedicine by provider organizations in California and Colorado, enabling better care to far-flung patient populations throughout the western region. In a companion piece beginning on page 22, Perna interviews scheduled keynote speaker Jane Brock, M.D., who lays out her vision of the proper role of IT in care transitions. On page 23, Hagland provides a recap of a panel discussion on health plan-provider collaboration around data and evolving changes in contracting relationships. The topic was one of the highlights of the Health IT Summit held in Chicago in June. In another area, Associate Editor Rajiv Leventhal reports on how the Cleveland, Ohio-based MetroHealth health system was recognized by HIMSS Analytics as a Stage 7 ambulatory center for the sophistication of its electronic health records. All 18 of the health systems have now attained the “pinnacle achievement,” the result of a 15-year health IT journey. The story appears on page 26. The article on page 28 will be of interest to provider organizations undergoing ICD-10 implementation. Perna reports on a recent webinar, outlining five practical tips on how providers can make their organizations ICD-10 compliant during the extended deadline. MORE ONLINE:

Make sure you visit www.healthcare-informatics.com for the latest healthcare IT news, including HIE integration at Sutter Health, Stage 2 meaningful use, bundled payment contracting, accountable care workgroup recommendations, and how telemedicine is transforming care delivery.

2014 EDITORIAL BOARD Marion J. Ball, Ed.D. Professor, Johns Hopkins School of Nursing Fellow; IBM Center for Healthcare Management; Business Consulting Services, Baltimore, MD William F. Bria II, M.D. Chairman, Association of Medical Directors of information Systems (AMDIS) Tina Buop CTO, La Clinica de La Raza, Oakland, CA Bobbie Byrne, M.D. VP for HIT, Edward Hospital, Naperville, IL W. Reece Hirsch Partner, Morgan, Lewis & Bockius LLP, San Francisco, CA Christopher Longhurst, M.D. CMIO, Lucile Packard Children’s Hospital, Clinical Assistant Professor of Pediatrics, Stanford University School of Medicine, Palo Alto, CA G. Daniel Martich, M.D. Chief Medical Information Officer, UPMC Pittsburgh, PA

4 July/August 2014 • www.healthcare-informatics.com

Brian D. Patty, M.D. Vice President and CMIO, HealthEast Care System, St. Paul, MN Chuck Podesta SVP and CIO, Fletcher Allen Health Care, Burlington, VT Wes Rishel VP and Research Area Director, Gartner Healthcare, Industry Research and Advisory Services, Alameda, CA Benjamin M.W. Rooks Principal, ST Advisors, LLC, Evanston, IL Rick Schooler Vice President and CIO, Orlando Health, Orlando, FL Patricia Skarulis Vice President and CIO, Memorial Sloan Kettering Cancer Center, NY, NY Fran Turisco Director, Aspen Advisors, Denver,, CO Ferdinand Velasco, M.D. Chief Health Information Officer, Texas Health Resources, Arlington, TX

MANAGING EDITOR John DeGaspari [email protected] SENIOR EDITOR Gabriel Perna [email protected] ASSOCIATE EDITOR Rajiv Leventhal [email protected] ASSOCIATE EDITOR, READER ENGAGEMENT Megan Combs [email protected] SENIOR CONTRIBUTING EDITOR David Raths [email protected]

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EDITOR’S NOTES

Not Clueless, Courageous: What It Takes to Build an ACO from Scratch

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have to say that my attention was absolutely grabbed by the headline of a blog at Forbes.com this summer. The June 12 blog, by Forbes.com contributor Roger Dooley, was entitled, “Are You the One Executive Out of Ten Who Isn’t Clueless?” Now, who wouldn’t want to read a blog with a title like that?? What’s more, Dooley’s opening paragraph was a grabber, too. Here’s what he wrote: “If you ask Mark Hagland executives whether they study the available data before making an important decision or just shoot from the hip, it’s likely that just about every one will say they take the data-driven approach. A study reveals the truth: decision-makers do indeed look at the data, but only one out of ten does what the data suggests if it contradicts his or her gut feeling!” (Exclamation point Dooley’s.) Further, Dooley went on to write, “The Economist’s Intelligence Unit surveyed several hundred international executives about their decision-making processes and reported the results in a commercial white paper: ‘Decision Action: How businesses make decisions and how they could do it better.’” As Dooley noted, only 10 percent of respondents, all senior business executives, said their decisions were driven primarily by intuition. Fully 90 percent said that they relied on data analysis, testing, and collaborative discussion, to make business decisions. Yet when asked the question, “What do you do when the data contradicts your gut feeling?” only 10 percent responded, “Do what the data suggest.” Thirty percent said, “Collect more data”; 57 percent said, “Re-analyze the data”; 30 percent said they would “Collect more data’; and 3 percent said, “Ignore the data” (outright). Of course, the headline, as it turns out, did slightly dramatize the actual results of that particular poll question. First of all, only 3 percent of the business executives surveyed said that they would actually “ignore the data,” whereas 60 percent would either collect more data or re-analyze the data involved. Certainly, those business executives could 6 July/August 2014 • www.healthcare-informatics.com

not fairly be characterized as “clueless,” as the headline suggested. The reality is that senior business executives across industries, and internationally, are regularly using a combination of data-driven analysis and intuition, to reach their strategic conclusions; to be honest, that’s good. Now look at the complex policy and operational landscape these days around the creation of accountable care organizations (ACOs), as described in this issue’s cover story (p. 8). Whether senior leaders at patient care organizations are considering participating in one of the Medicare Shared Savings Programs, or partnering with private health plans to create private-market contracts, they face a welter of elements to reflect on. The data, such as it is, tends to be rather inconclusive and difficult to rely on. After all, ACOs are new or new-ish creatures. No one has comprehensive data supporting all the financial, operational, and clinical/care management elements that must be considered in deciding to participate in such arrangements, because of their newness. The complexity involved in staggering. That having been said, the leaders of pioneering patient care organizations like Heritage Medical Systems, the Mount Auburn Cambridge Independent Practice Association, Crystal Run Health Care, Steward Health Care Network, and Mission Point Health Partners, are plunging ahead, and skillfully combining vision and strategy with the intellectual and tactical flexibility to make adjustments as they go along. They’re leveraging data, but are not slaves of that data. Really, that’s ultimately what will be required, going into these uncharted waters, filled with so much opportunity and so much challenge. Don’t worry, the provider leaders who are moving into ACO development aren’t clueless; they’re courageous. Their work will help lay the groundwork for the new healthcare of the coming decades.

Mark Hagland Editor-in-Chief

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COVER STORY 8 July/August 2014 • www.healthcare-informatics.com

COVER STORY

HIGH HURDLES LEADERS OF PATIENT CARE ORGANIZATIONS PARTICIPATING IN MEDICARE’S ACO PROGRAMS ARE RAMPING UP TO PUSH FORWARD INTO THE NEW HEALTHCARE BY MARK HAGLAND Critical Success Factors Leaders in ACO development stress the following critical success factors: • Early success in accurate patient attribution to one’s ACO, and in strong patient engagement with the ACO concept and with every attributed patient to her/his providers. • Early, strategic investment in data analytics and population health management tools, to perform accurate risk assessment on attributed ACO plan members/beneficiaries and to begin to marry claims data and clinical data from EHRs, for care and cost management and reporting. • The creation of skilled care management and data analytics teams. • More broadly, for some ACOs, a conceptual shift towards caring for virtually all of one’s patients in more or less the same way as an organization is caring for its ACO-attributed patients. • A cultural shift among clinicians and managers away from volume-based, fee-for-service-based care delivery and payment and towards value-based, accountable care delivery and payment.

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ith 368 Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) nationwide, and, according to recent estimates, well over 500 ACOs of some kind, including an ever-expanding group of collaborative arrangements between private health insurers and provider groups, the ACO concept is moving inexorably forward in U.S. healthcare. Indeed, even some of the challenges inherent in the shift to the ACO delivery-and-payment model—such as the announcement a year ago that seven of the Pioneer Medicare Shared Savings Program (MSSP) participant entities were shifting to regular MSSP status after failing to produce the level of cost savings expected of them under the terms of the Pioneer MSSP program, and two were leaving the MSSP program altogether—are leading to intensified

work to ramp up ACO cost savings and outcomes gains. A Leavitt Partners analysis published in the Health Affairs blog in June found that “The Pioneer program generated $147 million in total savings [in 2012], with approximately $76 million in savings returned to ACOs. Of the original 32 Pioneer ACOs, 12 shared in savings, while 19 did not share in savings or losses. Only one ACO shared in losses.” Meanwhile, as that same analysis found, “Of the 114 MSSP ACOs”—the non-Pioneer ACOs—“54 kept costs below budget benchmarks and 29 of those saved more than 2 percent, thus qualifying for shared savings.” In fact, the ACO development work taking place these days is accelerating in the context of significant gains in ACO reach across the U.S. According to a study released in April by the New York-based Oliver Wyman consulting firm, “More than twowww.healthcare-informatics.com • Healthcare Informatics 9

COVER STORY

thirds of the U.S. population record (EHR); but the now live in localities served authors immediately by accountable care orgaconceded that such nizations and more than 40 an approach would be percent live in areas served “expensive, disruptive, by two or more.” Specifically, and nearly impossible the Oliver Wyman researchto achieve in a disers found that 67 percent of seminated organizathe U.S. population lives in tion.” So what are the a primary care service area leaders of ACOs, both with at least one ACO, comMedicare MSSP entipared to 45 percent in Septies, and private ACOs, Gregory Spencer, M.D. tember 2013. That analysis doing to overcome the was commissioned by the broad strategic and Department of Health and IT-strategic challenges Human Services. The same inherent in the shift to report cited 368 Medicare this new model of care ACOs nationwide as of delivery and payment? April, and 522 ACOs of some DIVERSE EFFORTS kind, according to the Oliver TOWARDS THE Wyman estimate. SAME BROAD Still, though the Oliver GOALS Wyman report read as bullACO leaders interish overall (and the federal viewed for this story all Centers for Medicare and agree on one thing: creMedicaid Services was able Barbara Spivak, M.D. ating, developing, susto report a total cost savtaining, and expandings among all MSSP ACOs ing accountable care of $380 million in the first year of the program in 2012, $126 mil- organization models of all types is a very lion over targeted savings), it did note challenging and complex undertaking. a number of challenges, particularly At the same time, all are optimistic about on the strategic IT side of things. Its the long-term prospects. Among the orauthors noted that, “As healthcare pro- ganizations making significant gains: viders experiment with new ways to de- • The Northridge, Calif.-based Heritage Medical Systems is operating one of liver care, their IT systems have a hard the nation’s largest Pioneer MSSP time keeping up: traditional systems ACOs, with about 90,000 members, can’t support coordinated care, they do called the Heritage Pioneer ACO. That a poor job of maintaining relationships ACO, reports president Mark Wagar, with patients, and they don’t even supwas one of two ACOs that generated ply the basic data needed to manage a

WE’VE LEARNED A LOT AND HAVE BEEN ABLE TO INSTITUTE INFRASTRUCTURE THAT GOES ACROSS PAYERS, AND THE INFRASTRUCTURE HAS BECOME SOMEWHAT PAYER-AGNOSTIC. —DOMINIQUE MORGAN-SOLOMON contract based on value.” Further, the report noted that, in an ideal world, ACOs would simply compel every participant entity (physician, physician group, hospital, etc.) involved in the same ACO to adopt the same core electronic health 10 July/August 2014 • www.healthcare-informatics.com

40 percent of the savings documented in 2013 in the Pioneer MSSP program (the other was the Montefiore Pioneer ACO in New York City). What’s more, Wagar notes, the Heritage Pioneer ACO is composed primarily

of independent (non-salaried) physicians in California, Arizona, and New York, making that achievement even more noteworthy. • In Massachusetts, the Brighton-based Mount Auburn Cambridge Independent Practice Association (MACIPA), with over 500 physicians practicing in 10 communities, is also a Pioneer MSSP, reports Barbara Spivak, M.D., MACIPA’s president. The organization is making headway, she says, and moving forward under the banner of improving care through better care coordination. • In New York state, the 300-plus-physician, 17-location Crystal Run Health Care is participating as a regular MSSP, uniting its doctors and other clinicians as they strategize around getting ahead of the curve in value-based healthcare on behalf of its patients in Orange, Sullivan, Rockland, and Westchester counties in New York state, reports Gregory Spencer, M.D., the multispecialty medical group’s CMO and CMIO. • In the Boston metro area, the Steward Health Care System is participating in the Pioneer MSSP program as Steward Health Care Network, reports Dominique Morgan-Solomon, the ACO’s vice president of population health. Steward Health Care Network has worked through the initial issues around attribution, and is moving ahead on numerous fronts, particularly in terms of data analytics around population health, Morgan-Solomon says. • Meanwhile, the St. Louis-based Ascension Health, the largest not-forprofit health system in the U.S., has chosen to create Mission Point Health Partners, a Medicare MSSP ACO caring for more than 100,000 members across middle Tennessee, says Jason Dinger, president and CEO of the Nashville-based Mission Point Health Partners. The focus there has been ramping up quickly around data analytics to identify the ACO members in need of the most intensive medical interventions and care coordination.

ATTRIBUTION AND PATIENT ENGAGEMENT Wagar, Spivak, Spencer, Morgan-Solomon, and Dinger all agree that the

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COVER STORY

initial challenges facing ACOs sharing and analytics activity on the strategic, operational, on a mass scale. and IT fronts are inevitably Meanwhile, immediately daunting, but all feel their orrelated to the attribution issue ganizations, all of which have is patient engagement, says been participating in one of Morgan-Solomon. “To begin the Medicare programs, either with, they’re not always sure Pioneer or regular MSSP, since they belong to us,” she notes. sometime in 2012, have been “You’ll potentially have a benmaking steady progress. eficiary who has seen one of Importantly, says Morganour providers a few years ago, Solomon of Steward, “What we maybe via a specialist in our Dominique Jason Dinger learned early on is that about network, but their primary Morgan-Solomon 30 to 40 percent of our popucare provider is with a differlation in the MSSP is changing such that all the programs tend to be ent system. One of the chalevery year; that’s really significant, and applicable. I think the team was a bit lenges has been, how do you get these it makes you really think about how you surprised by that.” That area of learning beneficiaries engaged? In some cases, they haven’t realized they’re attributed to us. They have to opt in, and they get letters from CMS; but imagine, for populations who may not have caregivers who can explain everything to them, they can actually become very confused about all this. We’ve had to get pretty creative there.” “The attribution piece is huge,” agrees Crystal Run’s Spencer. impact ACO members right away,” she came after the initial hurdle of ensuring “Really, every payer is slightly different, says. “Typically, with care management accurate attribution (making sure that and it might seem simple, but it’s not. and population health, you’re trying to ACO patients were correctly identified), What do you do with people who see a institute interventions upstream, and something that every executive inter- lot of urgent care but don’t really have a that’s challenging. Interestingly, while viewed for this article agreed inevitably regular primary care physician? By bethe majority—though not all—of our poses a strong initial challenge. ing attributed, you’re saying, you might MSSP ACO members are over 65, one of Among the other core challenges get some sort of PMPM [per member the things we’ve learned” in participat- in the strategic IT sphere faced by or- per month] payment, and that’s good; but if you’re now responsible for the outcomes metrics for a patient and you don’t have a relationship with that patient and aren’t able to hit the quality gates, you’ve missed your opportunity for savings.” It is vital to get attribution right, and to link successful attribution with successful engagement of all active patients in the ACO, he says.

THE ATTRIBUTION PIECE IS HUGE. REALLY, EVERY PAYER IS SLIGHTLY DIFFERENT, AND IT MIGHT SEEM SIMPLE, BUT IT’S NOT. WHAT DO YOU DO WITH PEOPLE WHO SEE A LOT OF URGENT CARE BUT DON’T REALLY HAVE A REGULAR PRIMARY CARE PHYSICIAN? —GREGORY SPENCER, M.D.

JUST BECAUSE YOU’RE AN ACO PATIENT NOW AND WANT TO GO TO A MEDICARE ADVANTAGE PLAN OR VICE VERSA—WE SHOULD STILL BE ABLE TO WORK WITH YOU AND YOUR DOCTOR, IN EITHER ENVIRONMENT. —MARK WAGAR

ing in the MSSP program is that “while you’d think there would be a lot of differences between the Medicare and commercial populations, there really haven’t been a lot of differences. We’ve learned a lot and have been able to institute infrastructure that goes across payers, and the infrastructure has become somewhat payer-agnostic. Because really, the high-risk diabetics are 12 July/August 2014 • www.healthcare-informatics.com

ganizations moving into accountable care are: building strong data analytics teams; creating the decision support tools and performance dashboards needed to keep physicians focused on delivering optimized care; optimizing EHRs to support data-gathering and data analysis; and creating data warehousing and health information exchange infrastructures to support data-

SHOULD ACOS TREAT ALL THEIR PATIENTS IN THE SAME WAY? Once one begins to get a handle on the attribution/patient engagement issue, the most immediate set of challenges, all those interviewed say, is inevitably around data analytics, and around working with claims and clinical data in an analytics context. Dinger and his colleagues at Mission Point have been

scientific officer. At the moment, UPMC is not involved either in any of the Medicare Shared Savings Programs, or in a formal private-payer ACO; but the fact of having its own robust health plan is pushing the system inevitably down the same type of road as organizations that are participating in formal ACOs. Overall, what we’ve got here,” Shapiro says, “is a patient-centered medical home-based model, with an ACOtype structure. Nearly all of our 600 employed primary care physicians are involved in a PMCH-type structure, and then we’ve got virtual arrangements with our independent physicians with our ACO-type structure.” What that set of interconnected relationships inevitably leads to, Shapiro says, is this: “In year one of this work, the biggest issue is culture. The physicians who want to ‘own’ their patients and have access to them immediately, are focusing on keeping those patients out of the hospital and the ED, and are doing the best” in terms of care management. Even though their organization is not participating in an explicit federal ACO, the internal health plan-health system linkage, he notes, means that “Since we can attribute those patients who are the high utilizers, we’re able to move that top five percent who account for almost 50 percent of our costs into care management, where they’re being managed by a specific team that really does a lot of care coordination, and monitors them carefully.” What’s clear, he adds, is that “Though we’re still trying to figure out what an optimal care management team is, it’s clear that there are a lot of structural things we can do to communicate optimally with our patients, and to segregate them by risk, and optimally manage them accordingly.” In fact, he notes, UPMC is developing specialized medical homes for patients at the highest risk in terms of their identified congestive heart failure and chronic obstructive pulmonary disease (COPD).

COVER STORY

working with the Washour populations.” What’s ington, D.C.-based Adimportant, he says, is visory Board Company recognizing that “Just in that area, leveraging because you’re an ACO a solution from that orpatient now and want to ganization’s Crimson go to a Medicare AdvanAnalytics suite, one of the tage plan or vice versa— many analytics solutions we should still be able to options available on the work with you and your market now. Speaking of doctor, in either envithe need to plunge into ronment.” that area, Dinger says, Indeed, Wagar’s comSteven Shapiro, M.D. “One of the most imporments reflect those of tant things we’ve done is Steward’s Morgan-Solothat we’ve made significant investments mon, around shifting their entire orgain data analytics and data mining tools, nizations towards thinking about all of with the express interest in understand- their patients—whether ACO-attributed ing our population and some of their or not—in the same way. “In terms of the unique needs. The technology really al- clinical intervention,” he says, “in terms lows us to find the most people in need, of the proactive outreach and gains for and to discern what kinds of services a population, we’re applying the same they need.” One of the key purposes he principles of care to all of our patients and his colleagues have invested in an now. Now in the prepaid population, analytics solution for has been for risk then the provider system is really emassessment; the solution they’ve cho- powered [800,000 patients] to use those sen, he says, “allows us to understand scarce resources in the most effective the historical claims that each mem- way. In ACO care, you still have a foot in ber has,” and links that data with EHR- the fee-for-service camp, and a foot in derived data on the same patients. “It’s the ACO camp.” But, he says, the shift into important for us to know how many accountable care inevitably prompts a

ONE OF THE MOST IMPORTANT THINGS WE’VE DONE IS THAT WE’VE MADE SIGNIFICANT INVESTMENTS IN DATA ANALYTICS AND DATA MINING TOOLS, WITH THE EXPRESS INTEREST IN UNDERSTANDING OUR POPULATION AND SOME OF THEIR UNIQUE NEEDS. THE TECHNOLOGY REALLY ALLOWS US TO FIND THE MOST PEOPLE IN NEED, AND TO DISCERN WHAT KINDS OF SERVICES THEY NEED. —JASON DINGER people have gotten a flu shot or a mammogram, for example, and to be able to identify gaps in their care management,” he says. With regard to analytics, Heritage Medical’s Wagar says that he and his colleagues have had a distinct advantage in “having been around in Medicare Advantage for so long. We took systems we had, and then built new ones” for ACO purposes, he says, “but we’ve built them in a way that would apply to all of

rethinking of core care delivery and payment models across the board.

RETHINKING HEALTH PLAN-PROVIDER BOUNDARIES At the vast, 20-plus-hospital University of Pittsburgh Medical Center (UPMC) health system, being an integrated health system that has its own providersponsored health plan is making a huge difference in this area, says Steven Shapiro, M.D., the system’s chief medical and

MANY HORIZONS, NEW OPPORTUNITIES AHEAD Working in an ACO context may be challenging, but it can also be rewarding and very stimulating. Such is definitely

www.healthcare-informatics.com • Healthcare Informatics 13

COVER STORY

the case at Crystal Run, where Spencer reports that the learnings coming out of its ACO work are contributing to the organization’s push into new frontiers. In fact, he says, “We have our application into the state of New York to create our own formal health plan, to be called the Crystal Run Health Plan.” If the state of New York approves Crystal Run’s proposal this summer, the health plan would go live in January 2015. That is quite an ambitious undertaking for a multispecialty medical group, and Spencer acknowledges its rarity. But, he says, “We really felt like we wanted to try to cut out a middleman, to not have a shareholder entity take a large percentage of profits off the table; that instead, we’d prefer to be on the top line of that, and be able to share a bit of the savings directly with purchasers, which would be employers, in our case, and of course, the consumers as plan members. We’ve been on a long journey forward on valuebased care already,” he adds, “and we felt that we might as well involve the patient, and kind of do performance

risk as well as insursave gobs of money. The ance risk.” He says concept became so poputhat “We’re going to lar that there are now a be a narrow-network lot of ACOs in name only. product. The majority Many people wanted to of the care would be be ‘modern,’ but weren’t performed by us.” really at the place where In the end, all those they could really manage interviewed for this populations.” article agree that Doing so, he emphasizthey’re in it for the es, requires a fundamenlong run, regardless tal cultural shift among Mark Wagar of what specific develphysicians, other cliniopments occur in the cians, and whole organiMedicare MSSP programs or in pri- zations, away from a volume-based, vate ACO-type arrangements. These fee-for-service-driven mentality, and healthcare leaders see the future of fully into a care management/populahealthcare in terms of shared risk and tion health/value-based mindset. “It’s responsibility and in terms of value- not easy to get there,” he concludes. based care delivery and purchasing, “You have to have the mindset of doand aren’t afraid of it. They also believe ing only what’s shown to have a posithat some of the naysaying coverage tive impact on the patient—the right of ACO development of late has very care and the right time, or stuff that’s much overdrawn. Says Crystal Run’s shown to be useful. It means looking Spencer: “Initially, there had been critically at what you’re doing and deso much hype around the Medicare livering just the right care, no more, no Shared Savings Programs for ACOs, less, at the right time and in the right with predictions that everybody would way, and that’s not easy.” ◆

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FEATURE

Full Speed Ahead? For Mobile EHR Adoption, Not Yet WHILE CONSUMER-BASED MOBILE HEALTH APPLICATIONS HAVE EXPLODED IN GROWTH, CLINICAL APPS FOR TABLETS AND SMARTPHONES ARE STILL MATURING BY GABRIEL PERNA

D

r. Lee Peter Bee, D.O. is one of those people who just can’t run at half-speed. Bee, an internal medicine doctor in Sesser, Ill., runs a six-employee independent medical clinic, Southern Illinois Medical Specialists. He is also a fellow with the American College of Osteopathic Internists, a trained chiropractor, who specializes in intervention pain management, and has a Masters degree in nutrition. He teaches stu16 July/August 2014 • www.healthcare-informatics.com

dents and second-year residents and works at an emergency room on the weekends. “You can’t be everywhere and anywhere at the same time,” says Bee, who seems to try anyway. Having worked at Fortune 500 companies including Apple and Canon before entering the medical field, Bee is fanatical about technology. He is a firm believer in the mobile revolution. Every single one of his employees was given a

Windows 8 Surface RT tablet. Personally, he uses an iPad and has trained Siri, Apple’s homegrown voice-assistant application, to speak and understand medical terminology so he can verbally document on a patient. The Windows tablets have voice assistants as well. Bee says he has also become adept at using Practice Fusion’s (San Francisco) mobile electronic health record (EHR) app, and as his clinic switches over to a Kareo (Irvine, Calif.) system,

work space. If you look at a chart on a smartphone or a tablet, there is limited real estate to show the pertinent information on a single screen,” he says. At Catholic Health Partners, clinicians can use the mobile app to review clinical Stephen Beck, M.D. information quickly and in front of the patient. However, a law in the State of Ohio requires two-factor authentication when electronic prescribing. This, Beck says, has required the organization to take a more cautious apA MATURING SEGMENT proach with the moIn a way, Bee’s experience bile EHR application. reflects where healthcare He says the health stands with mobile EHR apsystem plans on figLee Peter Bee, D.O. plications. While consumer uring out efficient mobile health (mHealth) ways to have the app revenue has exploded in growth, driven move beyond its limitations. by consumer demand in wearable techThe mobile EHR application market nologies as well as entries from multi- is so immature that the segment has not tudes of small and large players, clini- yet been reported on by KLAS Research, cal EHR applications on mobile devices a well-known industry vendor research remain a still-maturing segment. Those firm in Orem, Utah. Colin Buckley, strawho are using EHRs on a mobile device tegic operations direct at KLAS, says are typically doing so with software that this is because provider experience has has limitations (something that even been very thin in this area. a tech super user like Bee admits) and “We did a study last year on EHR usdoing so to compliment a desktop ap- ability, both on the hospital and ambuplication. latory side. We talked with CMIO types Catholic Health Partners, a large and had them rate levels of functionhealth system with 23 acute-care facili- ality,” Buckley reports. “Most of what ties and 1,500 ambulatory providers in we asked about were meaningful use Ohio and Kentucky, certainly fits that related functions, but we threw in moprofile. Stephen Beck, M.D., CMIO of bile. We asked how they would rate EHR the health system, says the organization vendor support for mobile, and only has made investments into mobile EHR half could even answer the question,” he technology, but the applications are notes. Those who would answer spoke only used as viewers to compliment the of an immature form factor and only a desktop application. few vendors stood out, he adds. “I’ve worked with several EHRs in the past, and the challenge around EHRs PUSHING INTEGRATION is that there is so much information to IN PITTSBURGH compile and to organize, it’s difficult Other research efforts confirm that to get all that information onto a small those like Beck and Bee, who are using

mobile EHR applications, are clearly among a select group. The New York City-based research firm Black Book Rankings recently surveyed more than 20,000 EHR users. Of those, only 11 percent of the respondents were mobile EHR users. Even then, respondents who reported using an app were sharply divided in user satisfaction. Large multispecialty clinics and group practices, hospitalbased practice staffs, and other large healthcare organizations were more content with their mobile EHR apps, while most independent practices and solo physicians did not have as positive of an experience. Doug Brown, managing partner and president of Black Book, surmises that because larger healthcare provider organizations can provide technical support staff for both software and hardware issues, there is more satisfaction. “The luxury of live, local support improves user satisfaction tremendously. Training, updates and retraining/refreshers is also conveniently provided and causes little disruption in productivity at hospital networked practices,” he says. At one large provider organization, the University of Pittsburgh Medical Center (UPMC), large investments are being made into mobile platforms around the idea of clinical data integration. UPMC has teamed up with the GE Healthcare/Microsoft creation, Caradigm, a Bellevue, Wash.-based healthcare analytics and population health vendor, and developed Convergence, a Windows 8.1 tablet-based platform. According to Rasu Shrestha, M.D., vice president, medical information technology at UPMC, the platform sits on top of the EHR. It gives providers a longitudinal patient record of vital information from multiple systems that can be used in multiple settings. Furthermore, it is integrated with the organization’s clinical care pathways application, which guides providers to UPMC-approved treatments for specific treatments. In terms of security, the problems that Beck has encountered at Catholic Health do not apply here, as this platform uses single-sign technol-

www.healthcare-informatics.com • Healthcare Informatics 17

FEATURE

its mobile EHR app as well. Moreover, he has set up intricate templates that help him complete detailed documentation notes on the app, and has it set up so it seamlessly and wirelessly integrates with the desktop application as well other clinical applications. To top it off, each room in his practice is equipped with dualscreens—mobile and desktop—so he can document and educate the patient simultaneously. In other words, he doesn’t run his mobile EHR strategy at half-speed. “If you don’t do it well, it’s very dangerous,” warns Bee about mobile EHRs.

FEATURE

ogy and multifactor authentication, he says. To Shrestha and others at UPMC, it comes down to embracing the mobile form factor and taking advantage of its potential. They’re not just investing in mobile for the sake of mobile. It’s about integrating it into the workflow, he says. “Our focus is not just on data and interoperability. With Convergence it’s on user experience interoperability. You’re on your mobile [device], [the app has a] beautiful visual, it’s not on just an EMR, there dozens of clinical information systems. You need to place an order to change a medication and it’s just a swipe away,” Shrestha says. The focus on workflow, he adds, is why UPMC went with Microsoft as its partner. The operating system fit into the providers’ workflow seamlessly because the clini-

18 July/August 2014 • www.healthcare-informatics.com

tuitive tools, and allow [doctors] to get a good sense of a patient’s in‘TECHIES AT HEART’ formation without havWhile Black Blook’s reing to go to multiple search shows a divide in screens,” Beck says. mobile EHR user satisThe idea of clinical faction, in a sense the efintegration is why Bee is forts at a large healthcare an advocate of HTML5. system like UPMC mirror He says the standard the mobile strategy of Dr. allows developers to Bee, at an independently application data that Rasu Shrestha, M.D. run clinic. Both small and can cross different platlarge providers are utilizforms. Connectivity as ing bits and pieces of how Dr. Stephen well as usability and intuitiveness are Beck at Catholic Health Parts envisions the elements to success in mobile EHR mobile clinical applications evolving applications, he says. over the next few years. For most though, this kind pertinent “Mobile technology will eventually mobile EHR adoption is still two to three evolve and make it easier for clinicians years away. As KLAS’ Buckley says, the to see smart trend lines and other in- providers on forefront of mobile EHR adoption are “techies at heart.” CIOs at provider organizations as well as the doctors themselves and even the vendors are too focused on meaningful use regulations to push forward of mobility, he says. Recent research from athenahealth, a Watertown, Mass.-based provider of a cloud-based EHR system, and Epocrates, an athenahealth service, confirms that sentiment. Last year, athenahealth found there was a decrease in the number of clinicians using tablets, smartphones, and desktop computers in their workflow because of the push to meet meaningful use standards. Eventually, observers like Buckley see that changing. Perhaps, it will come sooner rather than later. Ninety-one percent of physicians who responded to the Black Book Rankings survey said they plan on accessing their EHR through a mobile device by the end of this year. Whether that timeframe is optimistic or not, is to be determined. Either way, widespread adoption of mobile clinical applications seems to be inevitable. “As meaningful use dies down and as people get used to the EHR, vendors are going to be searching for more and more differentiation. There are a lot of opportunities to improve EHRs, but from an image point-ofview, they will put time and attention into mobility,” envisions Buckley. ◆ cal desktop operates on Windows as well.

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TELEMEDICINE UPDATE

Telehealth Makes Gains Out West HEALTHCARE PROVIDERS IN CALIFORNIA AND COLORADO ARE MAKING IMPRESSIVE GAINS LEVERAGING TELEHEALTH CAPABILITIES TO EXTEND THEIR MEDICAL SPECIALTY CARE DELIVERY TO FAR-FLUNG POPULATIONS BY DAVID RATHS

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t the American Telemedicine Association’s annual meeting in Baltimore in May, the buzz was about health systems increasingly incorporating virtual visits into their operations and how mobile technologies could play a role in enhancing telehealth’s value. That conversation will continue  July 22-23 at the Health IT Summit in Denver, sponsored by the Institute for Health Technology Transformation, or iHT2. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through its parent company, Vendome Group LLC.) At the Denver conference, three leaders in the field of telemedicine will come together for a panel entitled “The Convergence of Telehealth, Telemedicine and mHealth: Improving Quality and Access while Reducing Cost.” They are James Marcin, M.D., M.P.H., director of the pediatric telemedicine program, and a professor of pediatric critical care, at the UC Davis Children’s Hospital in California; Doris Barta, MHA, director of telehealth services, at the Partners in Health Telemedicine Network (PHTN), St. Vincent Healthcare, Billings, Mont.; and John F. “Fred” Thomas, Ph.D., Director of Telemedicine at Children’s Hospital Colorado (Denver). 20 July/August 2014 • www.healthcare-informatics.com

TELEMEDICINE UPDATE To preview their panel discussion, Healthcare Informatics Senior Contributing Editor David Raths spoke with Dr. Marcin and Dr. Thomas and asked them to share their perspectives on the evolution of telemedicine, its integration into clinical workflow and how mobile convergence is starting to have an impact.

BETTER ACCESS TO REMOTE POPULATIONS Healthcare Informatics:  Could you start by describing a little about your telemedicine program’s area of focus and geographical reach? James Marcin, M.D.: Because we serve a lot of rural areas in Northern California, UC Davis has invested in the use of this technology to address disparities to access for people living in rural communities. We use the technology in a variety of ways, including in pediatrics. We help sick children in rural hospitals and clinics with any specialty needs, whether it involves cancer, trauma, pulmonary health or immunology. John F. Thomas, Ph.D.:  At Children’s Hospital Colorado, many of our specialists are the only people who do what they do in the whole Rocky Mountain region. In so far as outreach, we would like to expand these unique services across the region and improve access. Overall, our efforts are aimed at how telemedicine opportunities apply to our strategic initiatives to improve outcomes, reduce costs, and improve access. HCI:  What are some ways that mobile technology and telemedicine might be converging? And what are some of the benefits? Marcin: A few years ago, telemedicine was typically a $15,000 telemedicine unit on one end and a $15,000 telemedicine unit on the other end, and some telecommunications in between, but advances in technology make solutions more mobile and lightweight. As a hub site, we still have a clinic, but now physicians are doing consultations from their offices. I used to have to go to the clinic where the equipment was. Now I can do a consultation remotely on my laptop or iPad. On the other end, the consultation might take place at the patient’s home. Whether they use videoconferencing or not, many programs are starting to incorporate more remote patient monitoring for things such as palliative care or glucose monitoring for diabetic patients. Thomas:  Platforms [with Health Insurance Portability and Accountability Act (HIPAA)-compliant desktop videoconferencing] are much more nimble for supporting primary care providers in rural settings. They are enabling organizations to start working on integrating behavioral health into primary

care settings, doing specialty care follow-ups, or even home-based follow-ups with patients and their caregivers to assure coordination of care after discharge and possibly prevent unnecessary re-hospitalizations.

WHAT ABOUT REMAINING BARRIERS? HCI:  Is telemedicine technology getting better and easier to incorporate into clinicians’ workflow? Marcin:  I think that it depends. If you are a tech-savvy person, you don’t consider the technology a limiting factor. But the technology is far ahead of the rules and regulations and the way health care is reimbursed. We are not able to take a fraction of the advantage we could if the way we are paid as clinicians took account of efficiency. We are not paid to keep people healthy; we are paid to see patients in clinics. In my opinion, the biggest barrier is the lack of alignment between reimbursement and providing quality of care. We know that mobile technologies can keep people out of the hospital. You can monitor all of your diabetic or hypertension or renal failure patients a lot better with mobile health and home monitoring, but doctors and hospitals are not paid to do that. Thomas: In the past, our telemedicine system was not integrated into the clinical workflow, and thus our physicians had to go to specific tele-enabled clinics for consultations. This required really motivated people and resulted in low usage. Our new platform allows for seamless integration into clinical workflows and results in a much more efficient process. HCI: Do you think the shift toward value-based purchasing in healthcare will make telehealth more attractive to payers, including the federal government? Marcin:  I hope so. In health systems where the incentives are more aligned, such as the Veteran Health Administration and Kaiser, they do lots of mobile and home health. As doctors and hospitals take on more risk with capitated or managed care models, you would expect the pendulum to swing, but we still have a long way to go in terms of moving from volume to value. Thomas:  We are working on population health-oriented pilots with our eye on what we hope will happen with global responsibility for care. They involve doing patient intake and discharge more efficiently, transitions from hospital to home, as well as how we handle specialist consults in rural places, so that all providers in a medical home are on the same page about the responsibilities of the patient, primary care doctor and specialist. I think telehealth plays a role in all of those areas. ◆ www.healthcare-informatics.com • Healthcare Informatics 21

CARE TRANSITIONS PERSPECTIVE

I.T. in Care Transitions: Don’t Let Perfect be the Enemy of Good HOW CAN TECHNOLOGY IMPROVE CARE TRANSITIONS AND REDUCE READMISSIONS? ONE EXPERT SHARES HER EXPERTISE BY GABRIEL PERNA

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he epicenter of the work to improve care transitions and reducing readmission rates might just be located in the shadow of the Rocky Mountains. Specifically that epicenter is Denver, Colo., home to the University of Colorado’s Health Sciences Center. This is where the Care Transitions Intervention program was developed in the mid 2000s by Eric Coleman, M.D., professor of Medicine and head of the Division of Health Care Policy and Research at the university. In its initial pilot run, the program, recognized by  Health Affairs  as influential and “widely disseminated,” helped reduce 30-day readmissions by 30 percent and 180-day readmissions by 17 percent at the locations within the health system. It cut costs by nearly 20 percent per patient and, according to  Health Affairs,  was adopted by more than 700 organizations worldwide. Naturally, replication was followed upon in Coleman’s home state. In 2008, the work from that initial pilot was further developed into a program through the Colorado Foundation for Medical Care (CFMC), the Medicare Quality Improvement Organization (QIO) for the state. Like the initial pilot, that work was successful, reducing readmission rates by 10.78 percent in northwest Denver. By the time the Centers for Medicare and Medicaid Services (CMS) required every QIO to work on integrating care across providers, Colorado was ahead of the game. Thus, it was no surprise that CMS funded CFMC to lead the Integrating Care for Populations and Communities (ICPC)

National Coordinating Center (NCC). Jane Brock, M.D., MSPH, medical director at Telligen (which recently acquired a substantial portion of CFMC’s business), is helping lead the center, which supports QIOs in achieving their goals in improving care transitions and reducing avoidable readmissions for Medicare beneficiaries.  Having worked in this environment, Dr. Brock can certainly share wisdom on how to improve care transitions and reduce readmissions. “We now know a lot about how to better support people during a transition of care. We need to ensure there is a verbal care plan being enacted across a variety of settings,” Brock says. On July 23, at the Hyatt Regency Denver Tech Center, Brock will talk about what she has learned in transitions of care and reducing readmissions as one of the keynote speak (Continued on page 25)

22 July/August 2014 • www.healthcare-informatics.com

PAYER-PROVIDER PERSPECTIVE

Payers, Providers, and Data A PANEL OF INDUSTRY LEADERS SHARE THEIR VIEWS ON HEALTH PLANPROVIDER COLLABORATION AROUND DATA BY MARK HAGLAND

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an payers and providers transform healthcare by transforming their contracting relationships, and by collaborating on data? While there is no unanimity on the answer to that question, the members of a panel of industry leaders agreed that things are at least moving in that direction. The panel discussion, entitled “Transforming the Payer-Provider Relationship: Aligning Business Models for Improved Outcomes,” was held on June 10 at the Health IT Summit in Chicago, sponsored by the Institute for Health Technology Transformation (iHT2). Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through its parent company, the Vendome Group LLC. Cynthia Burghard, research director at the consulting and research firm IDC Health Insights, moderated the panel. The panel's other members were Cathy Dimou, M.D., chief medical officer at Rush Health, the physician-hospital entity within the Chicago-based Rush Health System;  Dan Hounchell, COO of the Cincinnati-based HealthSpan health plan, which is owned by the Cincinnati-based Catholic Health Partners health system, the largest health system in Ohio, and which operates hospitals throughout Ohio and Kentucky; and Scott Sarran, M.D., divisional senior vice president and CMO, government programs, at the Chicago-based Health Care Service Corporation, an umbrella organization that encompasses the Blue Cross Blue Shield health plans of Illinois, New Mexico, Oklahoma, and Texas.

DIFFERENT PERSPECTIVES ON BROAD ISSUES The panel members discussed broad issues around payerprovider collaboration, value-based contracting, and datasharing. Each of the panelists shared perspectives gleaned from his or her organization’s work in this key sphere. Asked where the Rush Health people began their value-based healthcare work, Dr. Dimou said, “We decided to work with our employed population first, because we thought it would be a great place to start. We worked with Cigna,” she noted. “And we were able to actually look at shared savings with our physicians, and try to set up a pay for performance model that way. It was a good way of putting our toes in the water and trying to level off the cost curve in that way. We are just www.healthcare-informatics.com • Healthcare Informatics 23

PAYER-PROVIDER PERSPECTIVE starting to see outcomes in select patient populations. We’re looking at diabetes and hypertension and are starting to see a decrease in cost. We’re trying to figure out if the progress in terms of a decrease in cost and an improvement in outcomes is real, or is seasonal variation.” HealthSpan’s Hounchell noted that being provider-based health plan within his organization’s umbrella has supported a great deal of activity. “We’ve got a lot going on,” he noted. “Cincinnati was selected for the Comprehensive Primary Care Initiative; and partnerships with several local health systems; and we’re working on partnerships with health plans. What have been the key success factors for us? I hate to sound so blunt about it, but money really does talk for us,” he said. Physicians, he emphasized, will respond to

the flip side,” he added, “work with providers through some programs to focus on the very high-cost patients. There, we think value can be more immediately created.” The panel spent some time discussing the potential outcomes involving physicians participating in accountable care, value-based purchasing, patientcentered medical homes, population health management, and other emerging payment and delivery forms. But the Blues’ Sarran warned that the landscape for health plan-hospital collaboration is more fraught than is the landscape for health plan-physician collaboration, in these areas. “With physicians,” he said, “it’s fairly straightforward to articulate the situation for physicians and to create win-wins between us and the physician groups and for the patients, and we can do that through HMO products or shared savings. The reality is that simply by managing the network, we can create savings immediately. When we’re dealing with the hospital entity, though, the challenges are much greater. In the environment in which we operate,” he said, “there is an overcapacity of hospital beds. The fundamental challenge is that in shared savings or ACO or anything else, we cannot pay more for a hospital to empty a bed than to fill a bed. If there’s no substitute for filling beds, like maybe a lower-cost insurance product or something; if we can’t backfill, the hospital providers truly won’t do the heavy lifting to empty beds, or they’ll do it and lose on the deal, and it won’t be sustainable.”

WE ARE JUST STARTING TO SEE OUTCOMES IN SELECT PATIENT POPULATIONS. WE’RE LOOKING AT DIABETES AND HYPERTENSION AND ARE STARTING TO SEE A DECREASE IN COST. WE’RE TRYING TO FIGURE OUT IF THE PROGRESS IN TERMS OF A DECREASE IN COST AND AN IMPROVEMENT IN OUTCOMES IS REAL, OR IS SEASONAL VARIATION. —CATHY DIMOU, M.D. financial incentives, whether they bring gains or losses in the short term. With regard to his organization’s recent moves, he reported that Catholic Health Partners’ purchase last year of what had been Kaiser Permanente of Ohio, now HealthSpan, also included the purchase of the employed physician group of Kaiser Permanente of Ohio, now HealthSpan Physicians. “It’s all prepaid care,” he emphasized. “Just in the last six months since that acquisition, we’ve seen benefits. We see the benefit of the Kaiser Permanente model, but how do we adapt that to the Midwest? That’s what we’re trying to work out right now.” Importantly, said Dr. Sarran, “What creates sustainable change is when providers do things that reduce cost and improve outcomes. To [execute on] the Triple Aim, it’s going to require providers to reengineer care and processes. Our take on that,” from a health plan perspective, he added, “is that pay for performance is not sufficient. Simply changing from a volume- to a value-based payment system is necessary, but not sufficient. It’s got to happen in order to transform care for cost, but is not sufficient. So when there’s enough provider skin in the game, in terms of the percentage of their patient flow as well as dollars at stake per patient, to cause them to reengineer, and there’s enough physician leadership, and true support with data and analytics, that’s what we look for. On 24 July/August 2014 • www.healthcare-informatics.com

COLLABORATING ON DATA IDC’s Burghard asked the panel members about the degree to which genuine data-sharing  and data collaboration are taking place between health plans and providers right now. In response, Rush Health’s Dimou said, “Let me describe what Rush Health provides to our physicians. We have data on about 80 percent of our physicians on their claims, and we set up a data warehouse. On the employer side, we would need all of their claims data. We get claims data on a monthly basis, usually with a two-month lag; but it goes into a data warehouse, to give us information that helps us to ascertain likelihood to readmit. We get data that is actionable for the physicians to manage patients better.” HealthSpan’s Hounchell noted that “We share a lot of data; having a provider and plan together under one roof is great. But the question is, what do you do with the data? How do you make

PAYER-PROVIDER PERSPECTIVE it actionable? We struggle with it,” he conceded. “We’ll say in a meeting, well, this data is great, but what do we do this? We want to impact the total cost of care and outcomes, and we’re really struggling with that; that’s our experience right now.” Asked about physicians’ resistance to receiving and working with outcomes data, the Blues’ Sarran said, “There’s actually less and less data skepticism among physicians now. Risk adjustment is forcing us all to pay more attention to diagnoses, because the government can and does audit how we do it. We’re seeing a much more rigorous approach to capturing diagnoses in a complete and accurate fashion, on the part of providers, because if it comes to us in an incomplete form, we can’t transform it.” Rush Health’s Dimou added that “We try to marry the clinical and claims data, and basically, take the data out to the physicians; not so much say you’ve done well or badly, but help us to understand what’s going on with your patients. That’s the

key to getting physicians interested, which is presenting it as a problem for them to solve. Tell us where the errors might be; and we’re able to use our clinical data to support our findings and then come up with a solution to improve patient care.” Asked what has been learned so far at the Blues organizations regarding marrying claims and clinical data, Sarran said, “I think one take is to work backwards in data analytics from what you’re trying to do. If we’re trying to save money and improve care on your highest-cost patients, it’s teasing out who the people are who are your highest-cost patients, and then look at the factors contributing to their being your highest-cost issues. If you’re trying to improve Stars or HEDIS, you’ve got to have the right analytics loaded in your analytics system to spit out the exact event you’re looking for. It’s really understanding in a very discrete way what you’re trying to do with the care event, and aligning the data and the analytics with that.” ◆

CARE TRANSITIONS (Continued from page 22)

ers at the  Health IT Summit in Denver, sponsored by the Institute for Health Technology Transformation (iHT2). (Since December 2013, iHT2 has been in partnership with  Healthcare Informatics,  through its parent company, the Vendome Group, LLC.) During Brock’s keynote, she will broach where IT fits into transitions of care and what conceptually needs to be done to get the most out of health IT in this setting. As she sees it, many end-users and developers are too focused on the big picture when it comes to health IT products.

initiative that would better incorporate social notes into the electronic medical record (EMR). In most EMRs, she says, medical and social notes were documented in different parts of the record, and the latter was not visible to the receiving providers. “Many of those things have been solved now but it has taken a while,” Brock says, adding that the promise of IT is rooted in standardizing many things that have never been standardized. In many cases, Brock notes, that QIOs are putting in direct communication structures between providers because the IT is too complicated or not available. This kind of work MAKING REAL HEADWAY reflects her view on how health IT should fit BY TAKING SMALLER STEPS into transitions of care. She compares the pro“Historically, we’ve been trying to enact the percess to a car: “You want your car get from here fect, finished solution, and sometimes that has to there and it’s not relevant to understanding stood in the way of simpler steps,” Brock says. how it works,” she says. “There are incremental things that could be put When IT succeeds in this regard, it can proJane Brock, M.D. into place while we work on perfection, and yet vide a great deal of seamless help for providers. the work on perfection is so overwhelming that Brock uses the example of an electronic tool sometimes we let perfect be the enemy of good.” created by CMS to ensure consistent, standardBrock cites two examples. When her team began to work ized assessments of beneficiaries across settings, which can on coordinating care and reducing readmission rates, she cut down on duplicative work being done. wanted an electronic bulletin board for basic communications In the future, Brock expects health IT tools to evolve so between providers. She says that never happened because of they work in the background and assist transitions of care work being done on full interoperability and health informa- seamlessly. While the contract for the center from the original tion exchange. funding runs out in July of this year, she says CMS intends to There were similar frustrations when she tried to lead an continue the program. ◆ www.healthcare-informatics.com • Healthcare Informatics 25

EHR PERSPECTIVE

A 15-Year Health I.T. Journey to Stage 7 Recognition EIGHTEEN METROHEALTH FACILITIES ARE THE FIRST IN NORTHEAST OHIO TO REACH HIMSS ‘PINNACLE’ BY RAJIV LEVENTHAL

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n 1999, when the Cleveland, Ohio-based MetroHealth system went live on its electronic health record (EHR) with its first ambulatory site, the underlying mission of the organization was to implement health IT across the system—not for the sake of health IT, but instead to use it as an enabler to provide better healthcare at a lower cost, says David Kaelber, M.D., Ph.D., CMIO at MetroHealth. “At that time, we said that if we really wanted to be a healthcare system of the future, it needs to be technology-enabled,” Kaelber says. The culmination of that 15-year journey was recognition from HIMSS Analytics, the research arm of the Chicago-based Healthcare Information and Management Systems Society (HIMSS), which in June designated the MetroHealth System as a Stage 7 ambulatory center for the sophistication of its EHRs. All 16 of MetroHealth’s community health centers, along with the Cancer Care Center and the Women & Children’s Pavilion, have attained “the pinnacle achievement” on HIMSS’ ambulatory electronic medical record adoption model (A-EMRAM). Developed in 2011, the EMR Ambulatory Adoption Model provides a methodology for evaluating the progress and impact of EMR systems for ambulatory facilities owned by hospitals in the HIMSS Analytics database. Stage 7 represents the highest level of EMR adoption and indicates a health system’s advanced electronic patient record environment. During the first quarter of 2014, only 4.54 percent of the more than 24,000 U.S. ambulatory clinics in the HIMSS Analyt26 July/August 2014 • www.healthcare-informatics.com

ics database received the Stage 7 Ambulatory Award. MetroHealth is among the first safety-net health systems in the country to reach Stage 7 status, and the first to do so using the Verona, Wis.-based Epic Systems. It is also the first Stage 7 ambulatory health system in northeast Ohio, its officials say. It was a 15-year journey that required sustained commitment, Kaelber says. “For anyone that has gotten to Stage 6 or Stage 7,

EHR PERSPECTIVE either on the ambulatory or hospital side, it’s not something you decide in a day or complete in a year. It’s really something that takes years to do.” As such, it isn’t just the quick payoff to focus on, but instead the long-term payoff, Kaelber says. “With an EHR, it’s not about how can you get more patients in the door or how you can provide more cost-effective care this month or next quarter. [On the contrary], it’s about how we can do this over the next five to 10 years so the infrastructure will be in place to do all sorts of amazing things that lets us accomplish all of our goals. It’s an infrastructure investment,” Kaelber says.

engagement would be impossible without this EHR infrastructure,” Kaelber says. The technology infrastructure in place additionally helped the organization with referrals, notes Kaelber. Being an integrated healthcare delivery network, MetroHealth has primary care and specialty care physicians, and the majority of specialty care comes from referrals from the primary care doctors, explains Kaelber. As such, with new generation medicine, the idea is that the system can track if the referral actually happens and if the visit David Kaelber, M.D., Ph.D. occurs, which is different than old generation medicine. “We will reach out to the patient if that LEVERAGING THE EHR doesn’t happen in a given time period,” Kaelber says. “We According to Kaelber, one way MetroHealth’s EHRs have use one month from the date the referral was placed as our ensured better care is by providing raw data on how many metric, and previously, only 48 percent of the time was the patients are suffering from undiagnosed pediatric hyperten- referral completed or scheduled to be completed in a month. sion and alerting medical caregivers when a patient’s blood Now since we’re tracking the metric, we’re at a 60 percent rate. pressure merits follow through. “In 2007, we were the first That is only possible because of the EHR infrastructure,” says system to show that pediatric hypertension is only diagnosed Kaelber. about a quarter of the time, even though the data in the EHR Lastly, the health system has tracked incidental findings, needed to make the diagnosis is sort of just sitting there,” he or unrelated medical issues that pop up in treatment, ensursays. That revelation, says Kaelber, was considered a top-10 ing that they’re addressed in a timely matter, says Kaelber. breakthrough in cardiovascular medicine by the American Being a trauma center, people will come in on a routine basis because they had some sort of trauma, he notes. A lot of the time, the patient ends up getting a CT scan or something similar from head to toe. As a result of that, it’s not super infrequent that even though the imaging test is ordered for something else, the radiologist will find Heart Association. “Since then, we have actually put in something that is not an emergency but really needs to be mechanisms to improve the diagnosis, and with the EHR, you followed up on, Kaelber says. can study the care that is being provided to patients in ways The classic example, he explains, is if someone is in a car that are impossible to do without it. And then you can identify accident and suffers a chest injury. At that point, the patient opportunities to improve the care as well.” will get a CT scan of his or her chest, and from a trauma standAnother way the health system has leveraged the EHR has point the patient might be fine, but the radiologist could see been by reminding patients when they are due for an immuni- a little nodule in the lung, which could be early lung cancer. zation. “We leveraged the idea that most of the patients in the It just so happens that the patient got the scan for something MetroHealth system get their care exclusively in that system, else, notes Kaelber. so we used the infrastructure that we had in place to see who “Someone has to follow up on that,” he says. “We did not was behind on immunizations,” Kaelber explains. “About have a system in the older world to follow up. Now, in our fullytwo years ago, we used our medical records to proactively integrated EHR world, these findings are flagged, they come message people to find out who was behind on a vaccine, and across to our EHR, and then we can have systems in place to we found a significant improvement in our vaccination rates track it. We have automated messages to primary care phyas a result. We’re going beyond our four walls to tell patients sicians and letters that go to patients, so there are multiple that we are still thinking about you and concerned about your levels of enabling both doctors and patients themselves to care. Everything surrounding population health and patient make sure the findings are followed up on. When we track it,

FOR ANYONE THAT HAS GOTTEN TO STAGE 6 OR STAGE 7, EITHER ON THE AMBULATORY OR HOSPITAL SIDE, IT’S NOT SOMETHING YOU DECIDE IN A DAY OR COMPLETE IN A YEAR. IT’S REALLY SOMETHING THAT TAKES YEARS TO DO. —DAVID KAELBER, M.D., PH.D.

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ICD-10 PERSPECTIVE

Five Ways to Capitalize on the ICD-10 Delay BEACON PARTNERS CONSULTANT SUMMER HUMPHREYS SHARES TIPS ON HOW PROVIDERS CAN GET THE MOST OUT OF THE EXTRA TIME BY GABRIEL PERNA

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or many, the delay of the ICD-10 transition will require major revisions to their implementation plan. For others, the changes will be minor. Some won’t change a thing. A recent webinar, hosted by the Weymouth, Mass.-based consulting firm, Beacon Partners, articulated this discrepancy while providing tips to providers that are undergoing ICD-10 implementation. In a survey conducted during the webinar, 43 percent of attendees said they anticipated minor revisions to their implementation timeline, 23 percent said they were staying the course, and 16 percent said they were going to undergo major revisions to the timeline. While industry-wide  opinions seem to be split  on  whether or not  the delay was a  good idea, Summer Humphreys, executive consultant at Beacon, said that most providers still have a lot of work to go on implementation, even with an extra year. Humphreys shared five tips with providers on how they can utilize the extra time. Tip 1. Dual Coding: This can occur multiple ways, Humphreys said. It happens when one coder codes a record in ICD-10 and then performs crosswalk coding in ICD-9 when possible in a single session. It can also happen with two coders, one coding in ICD-10 and the other in ICD-9, or multiple coders coding in ICD-10. Dual coding can measure the impact ICD-10 will have on productivity while helping 28 July/August 2014 • www.healthcare-informatics.com

apply a standard measure of coding application, Humphreys said. Those who wish to dual code should figure out what specific areas to focus on, she said, and also create a diagram workflow process, she added. Tip 2. Create a Clinical Documentation Improvement (CDI) Program: This kind of program can capture and monitor key

ICD-10 PERSPECTIVE performance indicators (KPIs) and measure them against benchmarks, Humphreys said. It also gives an organization a better idea of its coding workflows and helps it to better understand where the problem areas might be. Of highest importance in this kind of program is to incorporate feedback from physician advisors and champions. In order to make a CDI program successful, she said organizations have to obtain physician participation and make them understand what’s in it for them. It’s critical to get buy-in from the hospital’s leadership team, she said. Tip 3:.Optimize Revenue Cycle Workflows: In a poll conducted by Beacon during the webinar, 81 percent of participants predicted that ICD-10 would have a significant impact on their revenue cycle. No matter what an organization thinks of the ICD-10 delay, Humphreys said she is fairly certain that there will be room for improvement in its revenue cycle management (RCM) when it comes to ICD-10. Some ways to optimize the process, she said, include meeting with frontline staff, using staff interviews to map out workflow diagrams and matching workflow to IT scripts/process flow, and rebuilding RCM workflows to fit employees. She also suggested analyzing which payers, providers, and coders have the highest denial rates to try and better understand those reasons for denials. This can help an organization evaluate how much time staff is

spending on claim resubmission and denials. Tip 4. Evaluate Computer Assisted Coding (CAC) Readiness: Humphreys noted that as of last year, fewer than 10 percent of provider organizations implemented CAC. She said that many organizations don’t have the budget for CAC and, because there are no standards within the systems, it can result in variations. On the other hand, CAC can increase productivity, coding consistency, create an audit trail, and it can be used in conjunction with the CDI program, she noted. To evaluate readiness for CAC, Humphreys said organizations should figure out how much electronic documentation they are doing and the costs and benefits of CAC within their specific organization. Even with the delay, if CAC doesn’t result in a 20-percent increase in productivity, it might not be worth it, she said. Tip 5. Test, Test, and Re-Test: Testing was one of the big issues  brought up by industry stakeholders before  the delay was announced. Humphreys recommended organizations create an internal testing plan for each of the ICD-10 touch points, beginning with the most important systems first. She said organizations should test systems more than once using a varied data sample. Lastly, she said organizations should take the extra time to reach out to payers and external reporting agencies to test on that end.  ◆

EHR PERSPECTIVE (Continued from p. 27)

we see a substantial decrease in time between when the finding is found and the follow up,” Kaelber says.

MORE THAN JUST TECHNOLOGY While MetroHealth has had plenty of success in developing and leveraging its EHR infrastructure, Kaelber says that the organization’s mission is not health IT, but rather accomplishing the organization’s goals by enabling health IT. In addition to technology, there is a strong need for senior leadership in an industry where high level executives are constantly in flux. “Leadership changes, and has changed for us over our 15-year

as well as what is coming,” he says. Kaelber says that a lack of senior leadership, focus, and commitment are why many organizations have not yet gotten to a Stage 6 or Stage 7 level. “Ultimately, to do something big such as an advanced EHR infrastructure, you have to understand what the value is to you and your organization,” he says. Kaelber feels that healthcare reform is helping because there is more emphasis financially placed on population health management. “Are you interested in providing costeffective, efficient, high-quality care? You have to answer if an EHR infrastructure will help you do the things you want to do,” he says. “But what’s nice,” he continues, “is that now there are specific examples of technology helping healthcare systems that people in the ‘laggard’ category can point to.” However, the key is patience, as reaching the level of a paperless environment takes years and years, albeit maybe not 15 years like it took MetroHealth since technology is much more robust, Kaelber notes. “I do think that many places are somewhere along that journey and in that process right now. I would expect that in next three to five years there will be significantly more places that reach the Stage 7 level on both the hospital and ambulatory side.” ◆

ARE YOU INTERESTED IN PROVIDING HIGH-QUALITY CARE? YOU HAVE TO ANSWER IF AN EHR INFRASTRUCTURE WILL HELP YOU DO THE THINGS YOU WANT TO DO. —DAVID KAELBER, M.D., PH.D. journey,” he says. “CIOs, CMIOS, and CEOs all changed over that time. So how do we continue to push the roadmap? When we started in 1999, the concept of a personal health record didn’t exist, nor did the concept of health information exchange (HIE). You need to be a fast follower of what technology can enable, and have to have a pulse of what has come out

www.healthcare-informatics.com • Healthcare Informatics 29

MOBILE HEALTH UPDATE

How a N.J. Medical Center Saved Millions With mHealth Technology A SMARTPHONE APP HAS IMPROVED EFFICIENCY THROUGH BETTER COMMUNICATIONS ACROSS THE MEDICAL STAFF BY RAJIV LEVENTHAL

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ommunication breakdowns in healthcare affect care teams and their patients at every stage of the care process, from diagnosis to treatment.  Without a network to enable rapid connectivity and remote communication, clinician efforts are hindered while quality of care, patient satisfaction and cost efficiencies suffer. To quantify the effect that communication breakdowns could have on health systems, The Joint Commission, a healthcare system standards and oversight organization, has indicated that nearly 80 percent of serious medical errors and medical mistakes are caused by poor communication between healthcare providers or healthcare teams, especially when a patient is transferred from one facility to another. Undoubtedly, the time it takes for clinicians to reach each other drains staff productivity and creates delays in decision-making regarding critical patient-related issues. To this end, just a few years ago, officials at the New Jersey-based LibertyHealth Jersey City Medical Center estimated that medical staff spent about 15 percent of their day (or a month every year) trying to get hold of other physicians, rather than taking care of patients. Additionally at the 300-bed facility, surgeons reported 2- to 4-hour delays between 30 July/August 2014 • www.healthcare-informatics.com

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MOBILE HEALTH UPDATE the time that consults were requested and the time that they were notified, while residents reported up to two days’ lag time in getting response on consults. What’s more, after procedures, surgeons also faced difficulties communicating their findings and recommendations to referring physicians, who were often disconnected from the hospital’s communication system. These numbers were derived from interviews conducted by Practice Unite, a Newark, N.J.-based subset of Navio Health,

MILLIONS IN SAVINGS Since implementation of the Practice Unite application, the results have certainly been there. After about a year of using the technology, Jersey City Medical Center officials believe that the app has saved the organization at least $2 million in three key areas. The first has been in the observation unit; like many hospitals, Jersey City Medical Center created a care unit specifically to manage its observation patients. The success or failure of this observation initiative has depended on the ability of care teams to diagnose, treat, and either admit or discharge patients in less than 24 hours. (The Centers for Medicare & Medicaid Services (CMS) reimburses hospitals for observing patients using composite ambulatory payment classifications, a system that reimburses acute care facilities for outpatient services). Typically, when a patient enters the observation process, a cascade of phone calls begin that are meant to connect the treating physician with the patient’s primary care physician, consulting specialists, nurse practitioners, nurses and therapists. These care team members must rely on inefficient forms of communication to share lab results and other clinical data in order to make treatment decisions. Depending on the nature of the case, this can involve repeated calls to operators and answering services throughout the patient’s stay. Consultations requests transmitted through traditional hospital communication channels can take hours to reach specialists, and cause further treatment delays, according to Adam Turinas, CEO of Practice Unite, who worked with Jersey City Medical Center to obtain the details of the organization’s savings. At Jersey City Medical Center, people running the observation unit say they were able to discharge 20 percent of patients a day earlier because of the app, as physicians were able to receive and share critical patient information in the form of secure images, texts, and real-time laboratory feeds using their mobile devices. Doing so effectively eliminating all delays caused by traditional forms of communication, Turinas says, further estimating that this reduced length of stay translated into saving the hospital $720,000 a year. Additionally with the app, communications are responded to six times faster, the medical center reported. Surgeons said that consult response times were reduced by from 2 to 4 hours to 15 to 30 minutes—just by implementing the mobile communication system that allows faster and immediate communication between physicians, nurses and staff. Emergency department physicians report moving patients through the ED 30 minutes faster than without the

IF YOU HAVE A DRIVER’S LICENSE IN NEW JERSEY, BUT YOU’RE STOPPED BY POLICE OFFICERS IN FLORIDA, THE OFFICERS CAN RETRIEVE YOUR INFORMATION VERY EASILY. THAT’S WHERE HEALTHCARE IS GOING, ALTHOUGH IT’S NOT QUITE THERE YET. BUT THAT LEVEL OF INTEGRATION IS WHAT’S NECESSARY. —STEPHEN LI a healthcare communications vendor. Over a year ago, Navio Health’s core product, Practice Unite—a customized, Health Insurance Portability and Accountability Act (HIPAA)-compliant smartphone application designed to improve communications and speed up workflow—was implemented at Jersey City Medical Center, with the goal of solving this increasing healthcare communication issue. “In any industry, communication is always a challenge, as no matter the sector, communication is the key to holding together the workflow,” says Stephen Li, Jersey City Medical Center’s CIO. “In healthcare, with all the changes that we’re witnessing, that communication challenge gets magnified because of the regulatory changes that are coming right after one another. Pagers are still common, but you have to wait until someone gets back to you. As such, society has embraced smartphones as the center of their communication,” Li says. Going beyond secure texting to help healthcare organizations make major efficiency improvements using practical, customized mobile applications, Practice Unite provides a platform for communication and collaboration that connects care teams and their patients.   For instance, older patients who go into the emergency department might forget the medications they are currently on, meaning there might be some medication interaction that will potentially affect the patient negatively, explains Li.   As such, the physician will have to check with that patient’s primary care provider (PCP), which can be very difficult to do because PCPs are extremely busy people, Li says. “I experience this situation with my parents, who are both approaching the age of 90. They’re kind of sure about their medications, but also not so sure,” admits Li.

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Healthcare

Informatics Healthcare IT Leadership, Vision & Strategy

P O D C A S T S

Healthcare Informatics Podcast Channel is now available! Listen to Leading HIT Luminaries on topics including: Health Information Exchange Meaningful Use Imaging Informatics Transitions of Care

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ACO PERSPECTIVE

The Experiences of M.D.-Led and Other ACOs: A Comparison A NEW HEALTH AFFAIRS STUDY LOOKS AT THE CHALLENGES AND OPPORTUNITIES FACING PHYSICIANS LEADING ACOS BY MARK HAGLAND

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n important new study has come out in the June 2014 issue of  Health Affairs.  The article, entitled “First National Survey of ACOs Finds That Physicians Are Playing Strong Leadership and Ownership Roles,” is authored by Carrie H. Colla, Valerie A. Lewis, Stephen M. Shortell, and Elliott S. Fisher. In that article, the healthcare policy researchers note that they fielded a first national survey of accountable care organizations (ACOs). As they note in the article, “We found that 51 percent of ACOs were physician-led, with another 33 percent jointly led by physicians and hospitals. In 78 percent of ACOs, physicians constituted a majority of the governing board, and physicians owned 40 percent of ACOs. The broad reach of physician leadership” in ACOs, the authors note, “has important implications for the future evolution of ACOs. It seems likely that the challenge of fundamentally changing care delivery as the country moves away from fee-for-service payment will not be accomplished without strong, effective leadership from physicians.” The researchers say in their article that “We were broadly inclusive of potential ACOs in our initial population. In all, 292 organizations were deemed possibly eligible and were invited to participate in the survey.” In the end, 173 ACOs completed the full survey. What the researchers found was a number of revelations, some of which might surprise some in the healthcare industry. 34 July/August 2014 • www.healthcare-informatics.com

Among other noteworthy findings of the survey: • Overall, physicians owned the equipment and employed the staff in 40 percent of ACOs; • Physicians owned 62 percent of physician-led ACOs, compared to 16 percent in all other ACOs; • Importantly, physicians constituted a majority of the governing boards of 78 percent of all responding AcOs (94 percent of physician-led ACOs and 65 percent of ACOs led jointly by hospitals and physicians); • Physician-led ACOs had fewer primary care physicians and specialist clinicians, but included more individual medical groups than other ACOs; and • Among physician-led ACOs, 37 percent consisted solely of physician practices, compared to only 6 percent in ACOs of other leadership types.

ACO PERSPECTIVE Interestingly, the researchers found that physician-led ACOs were more likely than other ACOs to be participating in the general Medicare Shared Savings Program, but less likely to be participating in the Pioneer program, which is de-

The authors expressed concern over the capability of physician-led ACOs to access the capital needed to become robust; indeed, a quarter of the ACOs surveyed reported finding it “very challenging” to secure sufficient funds to launch an ACO, though that percentage did not change depending on whether an ACO was physicianled or not. Also of note, physician-led ACOs were as like as other types to report having advanced care management and health IT capabilities; yet fewer than half of all ACOs had those advanced capabilities. The researchers found that physician-led ACOs are leading in outpatient care management and health IT, but are lagging in their ability to manage across care settings (transitions and readmissions). Importantly, the authors note, “Because they are less likely to include hospitals or post-acute care facilities, physicianled organizations may face greater challenges than other ACOs in managing transitions between settings of care and managing hospital-based care, if it is provided by hospitalists who do not have a formal relationship with the ACO.” ◆

THE BROAD REACH OF PHYSICIAN LEADERSHIP HAS IMPORTANT IMPLICATIONS FOR THE FUTURE EVOLUTION OF ACOs. IT SEEMS LIKELY THAT THE CHALLENGE OF FUNDAMENTALLY CHANGING CARE DELIVERY AS THE COUNTRY MOVES AWAY FROM FEE-FOR-SERVICE PAYMENT WILL NOT BE ACCOMPLISHED WITHOUT STRONG, EFFECTIVE LEADERSHIP FROM PHYSICIANS. —FIRST NATIONAL SURVEY OF ACOs signed for large organizations prepared to take on financial risk. In fact, they found that while two-thirds of physicianled ACOs were participating in the Medicare Shared Savings Program, few were taking on downside risk. As it turned out, only 15 percent of physician-led ACOs were participating in the Advance Payment Program, which is part of the MSSP, but provides start-up capital to physician-based and rural providers.

MOBILE HEALTH (Continued from page 32)

system, reducing ED delays by 15 percent, notes Turinas. Lastly, the facility reported a savings of $120,000 per active physician user annually in referral leakage. This means that a patient who would otherwise be referred to a physician or service outside the area stays within the hospital network, Turinas explains. Li expects to achieve further gains in clinical productivity as Practice Unite is integrated with its electronic health record (EHR), scheduling and laboratory reporting systems. “As time goes on and as the industry builds out its communication ecosystem, places will begin to implement these applications as technology foundations,” he says. Using an analogy, Li says, “If you have a driver’s license in New Jersey, but you’re stopped by police officers in Florida, the officers can retrieve your information very easily. That’s where healthcare is going, although it’s not quite there yet. But that level of integration is what’s necessary,” says Li.

STAYING SECURE When sensitive health information is shared among healthcare professionals, there is a need to ensure that the content is secure, as it contains patient-specific information which can

be very sensitive to the individual. On the Practice Unite app, there is no information that resides on the smartphone, so there is nothing to worry about from a data perspective if the smartphone is lost, explains Li. “I compare the current state [of healthcare security] to three years ago, and there is more public awareness of information security based on a combination of more stringent regulation and also events such as the Target data breach, so the pendulum has really swung in terms of public perception,” he says. “They now understand it’s a necessary evil—the bad guy will get his information if there isn’t that level of protection.” When a healthcare organization evolves their communication ecosystem, this technology will help them with the security aspect, Li says. “You see the direction the industry is going. You’re talking about communication within and outside the hospital to other caregivers, to a PCP, to another urgent care center that also provides care for the patient. Pushing care out of the hospital and ultimately into the home is where the government is looking to drive down cost,” he says. “In the case of hospitals, volume is dropping, meaning revenue is dropping. You have to do more with less, and you thus need to look at vehicles that will gain cost savings and greater efficiency.” ◆ www.healthcare-informatics.com • Healthcare Informatics 35

HIE PERSPECTIVE

Sutter Health Goes NextLevel with Data Exchange LEADING CALIFORNIA HEALTH SYSTEM TO LAUNCH ITS OWN FULLY-INTEGRATED HIE BY RAJIV LEVENTHAL

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ust recently, the Sacramento, Calif.-based Sutter Health announced a significant step to improving care coordination and clinical quality across Northern California: the launch of a fully-integrated health information exchange (HIE) system. Currently, the Sutter Health electronic health record (EHR) from Epic connects five medical foundations and 17 hospital campuses. By 2015, it expects to complete its EHR installation to better support care delivery to three million active patients in more than 100 northern California cities and towns, its officials said in the announcement. An HIE system that integrates Sutter’s EHR with other providers’ systems will help Northern California caregivers improve quality, safety and efficiency for all patients traveling between providers, the organization’s officials say. Sutter Health is working with Orion Health to build and deploy its HIE, and will begin its work this summer in phases. The first step involves basic data integration with the Sutter EHR as well as testing the exchange of inbound and outbound data to ensure quality. Like many organizations, Sutter has been exchanging data for years, using the Epic platform, says the health system’s CMIO, Chris Jaeger, M.D. “But then in 2012, we began exploring the potential use of an enterprise HIE solution to broaden our exchange efforts.” Jaeger says he led a series of discussions with internal leaders and clinicians, which helped him educate stakeholders of the value of this exchange beyond what the organization was doing already. “That—in addition to the ongoing evolving healthcare landscape—let us see the potential value in implementing an HIE,” he says. 36 July/August 2014 • www.healthcare-informatics.com

EXPECTED GROWTH Being an open integrated delivery network, many of Sutter’s patients get care not just within Sutter but at other non-affiliated organizations such as dialysis centers, nursing facilities, and even competing hospitals and clinics, Jaeger says. “The HIE will allow us to create a community-based view of our patient’s information that all members of the patient’s care team, including their family, could see. Improved delivery of

HIIE PERSPECTIVE reliable information can be especially important expand in that area as other counties are able in emergencies—when every second counts for to take that information, he says. In the next patients in distress,” he says. year, Jaeger says he wants to be connected to Through that improved access to their inforat least three larger entities to help reach that mation and with secure communication, Jaeger critical mass. He notes that he would also like says Sutter expects to greatly improve care to see one of those entities connect to another coordination, especially across transitions of organization’s HIE, as HIE to HIE interopercare. “This in turn should help our patients and ability is a big step. their caregivers identify problems earlier, better Sutter also is doing a couple of alpha sites in manage chronic conditions, and have a proacthe coming months to confirm configurations tive rather than reactive approach, which we and technical infrastructure deployment to often see today. It should also allow us to more support inbound and outbound exchange, Chris Jaeger, M.D. effectively leverage population health tools and Jaeger notes. “In parallel, we are planning techniques,” he says. future stages, which will include more robust To that end, Jaeger sees an HIE as a “prereqdata feeds from Epic and through Orion HIE. uisite” for effective population health. “Without the HIE, we We will look to connect with larger care providers and reach would continue to have a fragmented view of our patient’s in- that critical mass as quickly as possible. Again, we want that formation. So the tools for helping support population health HIE to benefit external providers as well as internal ones. would not be as effective. The goal is to leverage the data you Since Sutter providers are already on an integrated EHR, will have already to manage the patient populations. If you have need to have external providers connected,” he says. fragmented data, you will be sending messages to patients or having false positive signals in your reports of populations FIGHTING THROUGH THE NEXT STEPS While Jaeger says the benefits to HIE are obvious, he notes about patients,” he says. Jaeger admits that launching an HIE is an ongoing effort that the greatest challenge for any organization implementing that will take years to fully develop—in that sense, you can’t an HIE is security. “We know the benefits, but the risks are even call it a project, he says. But with any HIE, the value of it is large as well,” he says. “We have a responsibility to take every possible safeguard to protect our patient’s health information, and work close with our technology vendors to ensure that we have robust safeguards in place that remain up-to-date.” There is also the challenge of helping smaller organizations that may not have the same amount of resources or expertise that Sutter has and is developing, Jaeger notes. “Under our HIE umbrella, we can really dependant on the network effect, he continues, referring help those organizations—if not connect to an HIE, get on to when you have reached a critical mass of participants and board for exchange doing Direct and Healtheway, and participate in broader things across communities nationally,” he data exchange to provide value to those on board. Thus far, Sutter has deployed Epic across all of its five says. Certainly as HIE continues to grow, healthcare organizafoundations, as well as 17 of 24 acute care facilities. “Unlike a lot of organizations that look at an HIE to help them connect tions are looking to address the problems they see as hamdisparate internal systems to achieve value, we don’t have pering the long-term success, stability, and sustainability of that problem,” Jaeger says. “We have that single system that health information exchange. To this end, Jaeger says that the we want to connect with our Epic EHR, and we will have them Office of the National Coordinator for Health IT’s (ONC) 10connected by end of the year to allow more seamless data year interoperability roadmap  articulates critical success factors for building blocks well in regards to long-term HIE exchange and visibility to providers within Sutter.” Already, Sutter is setting up basic data feeds from Epic to sustainability. “The framework, if successful, would help imthe Orion HIE, sending syndromic surveillance data to Califor- prove data exchange and integration across care teams, and nia’s San Mateo County, which Jaeger says is the only county give patients the ability to contribute to their own record,” he right now that is currently capable of accepting data in Sut- says. “Those would be truly remarkable accomplishments, if ter’s geographic blueprint. The health system will continue to we can do them.” ◆

THE HIE WILL ALLOW US TO CREATE A COMMUNITY-BASED VIEW OF OUR PATIENT’S INFORMATION THAT ALL MEMBERS OF THE PATIENT’S CARE TEAM, INCLUDING THEIR FAMILY, COULD SEE. —CHRIS JAEGER, M.D.

www.healthcare-informatics.com • Healthcare Informatics 37

MEANINGFUL USE UPDATE

Two CIOs Talk Meaningful Use Stage 2 EARLY ATTESTERS TELL HEALTH IT POLICY COMMITTEE ABOUT THEIR EXPERIENCE WITH HIE, PATIENT ENGAGEMENT BY DAVID RATHS

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o far, only 10 hospitals have attested to Stage 2 of meaningful use, but on Tuesday, July 8, the Health IT Policy Committee heard from the CIO of one of them and from another about to go through the process. Tom Johnson, CIO of DuBois Regional Medical Center, a 200-bed community hospital in rural western Pennsylvania, told the committee he believes his hospital was the very first to attest to Stage 2. He said the positioning for that success began with Stage 1. “We decided to go all in and exceed every measure,” he 38 July/August 2014 • www.healthcare-informatics.com

said.  His team did not ask providers to meet 5 or 10 percent thresholds, but to meet them with 100 percent of patients and included all menu items. “We integrated meaningful use into everything we did,” he said.   They worked to transform workflows, and participation was not optional for providers. “So our positioning for Stage 2 began with Stage 1,” Johnson said. DuBois’ strong relationship with its vendor Cerner was key in getting it where it is today, he added. The two major hurdles he noted involved patient engagement and health information exchange requirements. To

MEANINGFUL USE UPDATE engage patients in care, DuBois hired a full-time licensed practical nurse who went to every patient admitted and worked with them to encourage them to sign up for the portal so they could see their lab work online. “We only got 7 percent of patients enrolled. They are happy to see their labs, so view and download is happening, but I am not sure about the transmit part,” he said.

Health Alliance based in Johnson City, Tenn., said his organization has struggled with the rate of change meaningful use poses. Working with Siemens on its Soarian implementation, Mountain States just finished collection of data for a few of its hospitals June 30, and will begin attestation for the rest in October. “The pace is a problem for us,” Merrywell said. Both his organization and the vendor community have limited resources, he said. His organization has 90 clinics with 450 physicians. Some are superstar adopters, he said. “But there is another group who believe that the federal government and I are victimizing them in some way,” he said. Merryman said he was encouraged by the ONC’s recently published vision for interoperability, although he is discouraged that the estimate is it would take 10 years to get there. He also noted that the multiple government agencies involved in health IT do not appear to be on the same page and may be working at cross purposes. National Coordinator Karen DeSalvo, M.D., thanked the two CIOs for their comments, and in response to Merrywell’s comment about alignment, she noted that a reworking of the federal health IT strategic plan is under way, involving 36 departments and agencies and aligning reporting structures is one of its goals. ◆

WE ONLY GOT 7 PERCENT OF PATIENTS ENROLLED. THEY ARE HAPPY TO SEE THEIR LABS, SO VIEW AND DOWNLOAD IS HAPPENING, BUT I AM NOT SURE ABOUT THE TRANSMIT PART. —TOM JOHNSON DuBois already has remote connections to nursing homes and clinics, so there wasn’t much of a business case for creating new health information exchange arrangements, he said. “We had to get creative, and develop interfaces to overcome that measure. It didn’t add a lot of value for us,” he admitted. “It was a regulatory challenge, and to navigate the language, we leaned on Cerner to get over that hurdle.” Paul Merrywell, CIO at 14-hospital Mountain States

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If you’re in healthcare information systems and it’s time for a career change, get in touch with us at Belle Oaks of America. If you’re a healthcare software vendor, a health system, or a consulting firm put our 33 years healthcare IT recruiting experience to work on your hard to fill openings. Check us out at www.belleoaks.com Ed Simmons, CPC 772-492-1844 [email protected] Peter Converse 323-369-3447 [email protected] www.healthcare-informatics.com • Healthcare Informatics 39

CAREER PATHS

Interim Talent: A Growing Trend INTERIM EXECUTIVES WILL INCREASINGLY BE IN DEMAND. HERE ARE THE ELEMENTS OF A FRUITFUL ASSIGNMENT, BOTH FOR EMPLOYER AND EMPLOYEE BY TIM TOLAN

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he number of interim executives in the United Kingdom and other parts of the world is growing and the demand for interim talent is more than just noticeable. I sincerely believe this trend will become a growing part of the employment movement here in the U.S., particularly in healthcare, and especially in HCIT-related roles like CIOs and CMIOs. If you do simple math—with the projected Tim Tolan number of baby boomers retiring (10,000/day), coupled with the number of independent delivery networks and hospitals in the U.S., it’s easy to see that the demand will grow. The result? There will likely be a shortage of experienced healthcare executives moving forward, which means demand for interim healthcare executives will only grow over time. The interim world can be a bit tricky. In most cases, interim executives are hired to fill a gap left by the sudden departure of a key executive. Finding the right interim solution can be very challenging, especially when it comes to dealing with the permanent staff they will be leading. The hiring manager should ensure that an interim executive not only has the functional expertise to fill the role, but also has the temperament and demeanor to make

have been less than impressive. In my role, the timeline for my interim work was outlined up front, and I understood exactly what the company wanted from me. I found the work both challenging and exhilarating, and while I knew it was a short-term assignment, I found myself challenged by knowing each day mattered because I only had a certain amount of time to accomplish my goals. That was key for me. As we look ahead and you consider either taking on an interim role yourself or perhaps hiring an interim HCIT executive, make sure you evaluate candidates for the requisite skills required as if it were a permanent position. If you are taking on an interim role yourself, make sure you are able to check the following boxes: • Compensation (should be higher than your current salaried role); • Length of engagement; • Location in relation to your residence; • Employment status (W-2 employee or 1099 contractor); • Costs of benefits; and • Travel expenses to/from home at least twice monthly. Like any permanent role under consideration, make sure you like the person you will be reporting to; it matters so much. Talk to a couple of the people who you will be working with and try to understand the culture—even though you will only be a part of it for a short period of time. Also, make sure you have the authority to perform and execute against the goals and objectives you are hired to accomplish. Those goals need to be very clearly spelled out. Your role is critical to the organization that will be hiring you as an interim executive. They want you to succeed, and in order for both parties to do so, there must ground rules. It is very important that there is a clear understanding that your decisions can never be second-guessed by the executive team (unless it’s behind closed doors). The result would be a guaranteed failure that would be extremely difficult to overcome. As demand for interim executives increases, you’ll be ready to meet it with an informed mindset and everyone can win if you avoid potential problems up front and treat the interim role like the professional you are. ◆

FINDING THE RIGHT INTERIM SOLUTION CAN BE VERY CHALLENGING, ESPECIALLY WHEN IT COMES TO DEALING WITH THE PERMANENT STAFF THEY WILL BE LEADING. —TIM TOLAN sure there is continuity with the staff during this period of change and uncertainty. Understanding an interim candidate’s ability to navigate the leadership transition is key when walking into the abyss. I served as an interim executive vice president for a healthcare IT organization many years ago, and that experience showed me that with the right on-boarding and support from senior management, the outcome can be very positive. One of the keys for me was the support I received from the CEO and the leadership team. Without that support, the outcome and the results would 40 July/August 2014 • www.healthcare-informatics.com

Tim Tolan is senior partner of Sanford Rose Associates-Healthcare IT Practice. He can be reached at [email protected] or (904) 875-4787. His blog can be found at www.healthcare-informatics.com/tim_tolan.

iHT² Health IT Summit S Seattle, WA August 19-20, 2014 A

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Topics Include: Innovations in Population Health Management • Exchanging Data in Accountable Care Organizations • Innovative Encounter Models: Transforming Care with Mobile Applications • Transitioning from Volume to Value: Leveraging Analytics to Support Population Health • Stage 2 Meaningful Use Challenges: HIE and Patient Engagement • Extending the Reach of Care through Telehealth

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Nancy Vorhees Chief Operating Officer Inland Northwest Health Services

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