DIVURGENT S ACORM FRAMEWORK

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1 white paper DIVURGENT S ACORM FRAMEWORK The Right IT Infrastructure for ACOs written by David Shiple

2 CMS Is Driving ACO IT Planning After reading the final rule for Medicare Accountable Care Organizations (ACOs), one might conclude that the IT infrastructure needed to support an ACO is too daunting to build. CMS alludes to dozens of technological documents and processes in the rule, including electronic health records (EHRs), personal health records (PHRs), telehealth, health information exchanges (HIEs), data warehousing, analytics, and member registries. The resulting ACO IT platform would involve a very complex and expensive implementation. In fact, Medicare s estimate of $1.75 million for ACO infrastructure is a low estimate for most healthcare organizations. Healthcare organizations are likely to spend many times that amount to properly implement all the IT elements envisioned for Medicare ACOs. Furthermore, since implementing this type of ACO platform would require technology not readily available in the present marketplace, a considerable amount of custom development would also be needed. According to the final rule, a Medicare ACO is required to define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies. In applying to become an ACO, organizations must provide documentation describing plans to: Promote evidence-based medicine Promote beneficiary engagement Report internally on quality and cost metrics Coordinate care The language of the rule does not dictate the use of specific IT applications, but heavy reliance on IT is clearly the intent. Combining the language of meaningful use and ACOs makes it clear that CMS sees IT investment as a starting point on the road to healthcare reform. Of course, CMS is not the only payer experimenting with shared risk/savings models. Most in the industry would agree that some form of shared risk/saving model will soon be put to a test (and many such models adopted) in virtually every market in the U.S. Few of these private models are as complex as the CMS model, and therefore have a much lower IT hurdle to clear. As an example, one could envision effective care coordination being put in place in some markets by simply giving coordinators access to hospital and community physician EHR portals. ACO Reference Model (ACORM) DIVURGENT developed the ACO Reference Model (ACORM) to provide a conceptual framework for planning and implementing the various components of ACO technology architecture. While the model is intended to prepare health systems for a Medicare-like ACO, DIVURGENT believes that many organizations will need only a subset of the technologies described to meet their near-term needs. Improving healthcare with client focused solutions DIVURGENT - All Rights Reserved 1

3 DIVURGENT has carefully examined each component in ACORM and considered the role and implementation implications for each one. Before discussing these components in detail, this paper notes several overarching themes arising from ACORM: While much of the required IT investment for ACOs overlaps with Meaningful Use, most does not, and will require a new IT strategic planning approach. Much of the technology called for is not readily available in the present marketplace. One should expect many HIT products used by payers to be modified for use by providers. As incentives build to keep patients healthy and out of provider facilities, innovations in home health and telehealth technology will appear at an accelerated pace. Privacy and security infrastructure will take on heightened importance and complexity. Key ACO IT building blocks such as HIEs will quickly expand into new areas of functionality. While CMS may be calling for end-to-end HIT capabilities at the startup of an ACO, many private ACO s can start with HIT baby steps. ACORM Building Blocks PHRs: Personal responsibility on the patient s part is a key component of the ACO concept, and the personal health record (PHR) is designed to better equip patients to take ownership of their health. While a PHR is not necessarily required for patient accountability, it is the primary IT-enabler for promoting active patient participation. PHRs are often DIVURGENT - All Rights Reserved 2

4 part of a patient portal or HIE but may also exist in the cloud (as in Microsoft s HealthVault or WebMD Health Manager), as part of an enterprise EHR solution (such as Epic s MyChart), or on a custom website built by a health system. While PHRs are now part of the HIT landscape, challenges remain concerning longitudinal data aggregation, security, and patient adoption. Self-service: Web-based self-service tools that allow patients to make appointments, pay bills, communicate with providers, and update information online are often part of a patient portal. These tools can save patients time and money, improve patient satisfaction, increase patient stickiness to the ACO, and increase the likelihood that patients will use the PHR. As patients become more tech-savvy, they are increasingly comfortable with these types of applications and are also increasingly likely to demand them. Telehealth: Many interactions between patients and providers can be efficiently handled via or over the phone; however, because providers have not been traditionally reimbursed for these interactions, they have little incentive to use them. By contrast, e-visits and other forms of telehealth will be a fundamental component in controlling costs and improving productivity in an ACO. In-home videoconferencing is likely to become one of the most important avenues for patient-provider communication. EHRs: While the CMS ACO final rule does not mandate the use of EHR s, DIVURGENT believes EHRs are the fundamental building blocks of the ACO IT infrastructure. The cost of implementing an EHR is decreasing: for a mid-tier EHR, the one-time cost is about $20,000 to $30,000 per physician, with a yearly cost of about $5,000. At the same time physician adoption of EHRs is rapidly increasing thanks to HITECH incentives. In addition, EHR vendors are beginning to add modules that have value for ACOs, such as HIEs, benchmarking tools, physician-to-physician communication, and PHRs all positive market developments for ACOs. EHR Market Leaders ACO Enablers Community support providers: Other care settings besides physician offices and acute care hospitals will likely be included in many ACOs. These may include long-term care facilities, skilled nursing facilities, rehabilitation facilities, urgent care clinics, assisted living facilities, and hospice care. These settings pose special challenges for the ACO because they tend to be less automated, use non-mainstream applications, and often have less funding to contribute to shared components of the ACO platform. High-volume facilities will certainly need to be integrated into the ACO dataflow, with the initial focus on transition points (e.g., discharge from an acute care hospital to a nursing home) in order to ensure Improving healthcare with client focused solutions DIVURGENT - All Rights Reserved 3

5 that the correct information is exchanged and to reduce the risk of readmission. Health information exchanges: HIEs are the key enablers of care coordination and provide a view of each patient s longitudinal record. In addition to clinical data sharing, HIEs support such handoffs as referrals and care transitions. HIE functionality could expand significantly in the ACO setting. For example, most HIEs contain a data repository that could be used to feed a data warehouse. HIEs could also play a role in analytics (e.g., providing an ACO dashboard) and workflow transactions (e.g., transmission of care plans to all providers). HIEs have traditionally confronted the issue of financial sustainability; however, this may be of less concern in the future as HIEs are built into the ACO cost structure. As is currently the case, a workable governance structure must be established. Security and privacy measures will also add to the complexity of HIEs as greater numbers of providers and patients seek to access HIE data. HIE Market Leaders Data types Community data warehouses: Longitudinal data warehouses fed by disparate EHRs are not readily available in the marketplace, but are needed to support quality reporting, care management, care coordination, and other ACO requirements. Most enterprise vendors have not excelled at data aggregation in disparate EHR environments; thus such other strategies are being adopted as: Buying the starter set for a community data warehouse using such products as Orion Amalga, Recombinant, or Health Care DataWorks. Buying the data model from such vendors as IBM, Oracle, or Teradata as a starting point for building the data warehouse from the ground up. Relying on analytics specialists to combine and analyze data from various applications with such tools as SAS. In any case, robust longitudinal data repositories will be necessary for care coordination, analytics, and quality and financial tracking. Data analytics: Analytics may be the most powerful tool to ensure an ACO s survival. Analytics provide the ability to identify quality measures needing attention; physician performers and non-performers; areas of high cost; and the effects of cost reduction and quality improvement strategies. There are three major categories of analytics: DIVURGENT - All Rights Reserved 4

6 Generalized business analytics tools (e.g., Cognos, Business Objects). Healthcare-specific stand-alone tools (e.g., EPSi). Add-on modules from enterprise EHR vendors (e.g., Horizon Performance Manager, Sunrise Clinical Analytics). The last category has the advantage of easier data transfer from the EHR into an analytics environment with prebuilt dashboards and the like. The weakness of analytics products contained in the major EHR product lines is their inability to create a robust, extensible, longitudinal view of the patient s data, especially when disparate systems are involved. The ability to carry out successful analytics in real time depends on robust analytics tools; complete, accurate, and normalized data; and skilled data analysts. Key features will include complex queries, scheduled reporting, dashboards with drill-down 3-D data modeling, and alerts. Disease registries: Disease registries allow for voluminous granular data capture along the lines of specific diseases. EHRs do not contain comprehensive data for many chronic diseases, making registries an important element in chronic disease management. Registries also enable comparative effectiveness research by offering the ability to share data across regions or nationally. They allow ACOs to run more efficiently and hire staff members who specialize in specific diseases. Disease management: Disease management (DM) systems are often used by third-party DM companies focused on major chronic diseases. DM systems typically use claims as the primary source of data. A key aspect of DM systems is predictive modeling, which provides alerts for high-risk patients. DM specialists then intercede with the patient s primary care provider to mitigate the risk. Incorporating DM systems into an ACO IT infrastructure would greatly improve this process. DM specialists would be able to utilize granular EHR data and issue alerts directly to the physician via the EHR or to the patient via the PHR. Care management: Longitudinal care management (CM) has traditionally been the domain of payers using claims data as the primary data source. Similar to disease management, however, ACOs will require a much more granular approach to CM through using EHR data. Some CM vendors have positioned their products for providers; however, much functionality required by ACOs remains to be built. Market Leaders The development of comprehensive care plans appears to be part of the Stage 2 Meaningful Use objectives, making this functionality a necessary area of focus for HIT vendors. Care coordinators and managers are likely to become central figures in the ACO model through using data from the ACO s data warehouse to develop effective care plans. Care Improving healthcare with client focused solutions DIVURGENT - All Rights Reserved 5

7 coordination may even develop into a new specialty, with its own education, training, and certification requirements. Risk management: Actuarial services are likely to be delivered by nonpayer third parties and will include the handling of all financial aspects of the ACO. Other financial services related to ACOs are likely to be bundled as well: Fund accounting and distribution Audits of attribution model Audits of shared savings payments Savings maximization models Security infrastructure: Privacy and security in healthcare is increasingly important as the government continually steps up surveillance, enforcement, and penalties related to misuse of patient data. ACOs are especially vulnerable to privacy and security breaches; they face substantial challenges because of the large amount of data and large number of individuals (providers and patients) involved. Consider an ACO with 100,000 patients and 1,000 caregivers, in which every caregiver s data access will require: An appropriate business associate agreement The need to know An audit trail Rules detecting unauthorized access Protection against downloading patient data to a device that can be taken outside the provider setting This aspect of the IT infrastructure will need to be carefully monitored and is likely to become an especially challenging aspect of ACOs. Enterprise master patient index (EMPI): An EMPI provides a crosswalk to all of a patient s various identifiers (e.g., medical record numbers) housed in the disparate systems of an ACO. Probabilistic matching (for example, the use of DOB, SSN, last name, etc.) is often used to make a positive match between patients in two systems when unambiguous identifiers are not available. Because ACOs must track patients carefully across a number of care settings and providers, EMPIs are an important component of their IT infrastructure. Key challenges include data governance (e.g.. which entities can update core data), eliminating duplicates, and keeping the index current. Member registry: Timely and accurate dissemination of patient enrollment data has been a challenge to payers for years, but ACOs must adopt this capability as a core competency. Meaningful ACO performance tracking will depend on such features as the ability to accurately track stop/start dates in real time. It may be possible to adapt EMPI products currently on the market to hold registry indexes and fields DIVURGENT - All Rights Reserved 6

8 Conclusion ACO IT investment may rival or even surpass investments made by providers to meet Meaningful Use. Certainly those providers forming an ACO under the current CMS guidelines have a daunting IT hurdle to overcome. DIVURGENT believes that for most healthcare organizations, however, the investments can be modest and incremental. For many value-based purchasing arrangements, current efforts in the industry to clinically integrate physicians and hospitals (with IT playing a key role) are already moving healthcare organizations closer to ACO readiness. In any case, an IT strategic planning process that includes a systematic look at each technology component required for a successful ACO is a good first step. ABOUT THE AUTHOR David Shiple has more than 24 years of IT implementation and strategic planning experience. His background includes 15 years of IT experience in the healthcare industry where he has led a broad range of projects, including CPOE/Meaningful Use strategy and program management, health analytics strategy, community physician connectivity strategies, IT strategic planning, and best practices research. Mr. Shiple has worked for DIVURGENT since January Before DIVURGENT, he worked for companies such as Accenture, Gartner, IBM and Navigant. Mr. Shiple is an active member of is local HIMSS chapter, and has been published in periodicals such as HFM Magazine, Bio-IT World, and Modern Healthcare. COMPANY OVERVIEW DIVURGENT was founded by a team of consulting veterans who are well versed in the healthcare industry. As a premier healthcare consulting firm, DIVURGENT is focused on the business of hospitals, health systems and affiliated providers. We provide advisory, activation management, clinical transformation, and revenue cycle management services to help you improve patients lives. Recognizing every organization is unique, we leverage the depth of our experienced consulting team to create customized solutions, utilizing best practices and methodologies. Improving healthcare with client focused solutions DIVURGENT - All Rights Reserved 7

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10 OUR COMMITMENT DIVURGENT is dedicated to helping our clients improve their operational effectiveness, financial performance and quality of patient care. Through thought leadership, providing value for our services and delivering innovative solutions, we are committed to improving the quality and safety of healthcare delivery for our clients and the communities they serve. JOIN THE DISCUSSION. CONNECT! Innovative Healthcare Solutions DIVURGENT - All Rights Reserved 10/11

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