Today on MU Live Radio: ACOs & Meaningful Use Connecting the Dots

By Gregg A. Masters, MPH

ACOs, Meaningful Use (aka MU), the persistent ‘whitewater’ of health reform and the quest for the elusive ‘triple aim’ will be at the center of our chat today on Meaningful Use: MU Live Radio.

MU Live! is a 30 minute internet talk radio show hosted by our HITECH Answers experts. Our session experts discuss breaking news and issues on meaningful use as well as other health IT topics.

For more information including past guest segments, click here. To register to listen to today’s broadcast at 11AM Pacific/2PM Eastern, click here.

Inside ‘accountable care’, challenges to the ACO

By Gregg A. Masters, MPH

We hear considerable chatter on both sides of the ACO or ‘AC/e’ for accountable care focused enterprise absent the organizational drama of fielding an entity per se with the right structural roots or cultural ‘DNA’.

Yet, as someone with principal leadership immersion both setting up and managing the ACO ancestry down line if you will, I am mindful of the continuing granular nature of the challenge from the patient’s point of view.

When one considers the ‘faith based’ trust voucher like programs place on seniors becoming prudent (empowered) purchasers if not negotiators on their own behalf, the following experience raises some fundamental challenges in re-engineering a patient-centric healthcare eco-system.

In March of 2011 my 80 year old mother embarked on the labored journey of being ‘diagnosed’ and subsequently treated for breast cancer. The patient, an otherwise ‘age appropriate healthy’ and vibrant woman, took the parsed delivery and serial but strained confirmation of the diagnosis as an attraction into women’s health advocacy – I will explain shortly, and thus attempt to illustrate the accountable care challenge in this ‘n of 1′ experience.

I emphasize diagnosis with a mild dose of intentional sarcasm, as while the process played out it revealed multiple systemic flaws within our overpriced, discontinuous, and increasingly from a value proposition perspective ‘diminishing returns’ sick care ‘confederation’. Which according to Wikepedia is defined as:

A confederation in modern political terms is a permanent union of political units for common action in relation to other units. Usually created by treaty but often later adopting a common constitution, confederations tend to be established for dealing with critical issues such as defense, foreign affairs or a common currency, with the central government being required to provide support for all members.

But wait, this is offered in the context of a political situation. Precisely! Our healthcare, ah hem, metastasizing, commission based sick care fulfillment industry is very much a confederation of political sub-divisions defending their ‘turf’ if you will. Unfortunately in healthcare we lack the central unifying governmental role. Yet, in the typical hospital setting simply look at the political subdivisions of medical staff organization vs. an administration generally supported by a ‘paramilitary’ nursing organization, with more often than not a challenged Board of overseers given their stewardship agenda. Need another metaphor, check the myriad of medical specialty societies and watch them define and defend their interests, i.e., distribution of the cognitive vs. procedural income pie. Case closed?

Now back to the story, but first additional context to color the emerging irony. The source of my mother’s care is a indisputably a ‘best in class’ academic medical center (AMC) recognized by many third party authorities including HiMSS (the Health Information and Management Services Society) as a ‘level 7‘ (the best) facility in terms of it’s adoption and implementation of EHR technology as mission critical infrastructure.

One minor issue though is the ‘cancer center’ as a service line aggregating entity for the primary oncology specialties (e.g., hem/onc, radio therapy, etc.), is not online with the medical center’s EHR hub aka EPIC.

Yet the patient has been in a long term relationship with her primary care physician of at least seven years duration and who’s department, internal medicine, was the first service to go live with EHR implementation. Yet the primary care physician (and the entire department for that matter) was unaware of any of the patients experience or care process in the cancer center.

Thus a bit of a ‘data liquidity’ and patient care coordination challenge when it comes to a seamless patient experience relative to coordination and scheduling over certain legacy departmental silos. Remember the mantra of ‘patient centricity?’

Thus even in a top performing academic medical center that represents itself as a ‘health system’ in advertising and branding copy, the gaps in patient care are real and many. As a result, ‘accountability’ for the essential care coordination and broader navigation interests to obtain high quality and responsive care is in many instances deferred to the patient and his or her family as principal advocate.

Now back to the diagnosis issue. In March of 2011 an annual ‘routine’ screening mammogram created some diagnostic concern, as it was immediately followed by a (non routine) same day ultrasound. Shortly thereafter the departmental chair approached the patient with the following representation:

We see something we think is nothing but ask you to return in 6 months for a recheck [vs. the annual checkup interval]

The patient complies. Six months later a notice was dutifully received to return for the scheduled follow-up. This re-engagement interval began a series of progressively up-leveled and hierarchical interactions between an ultrasound tech, staff radiologist and ultimately the service or department chief with the following recommendation:

We still think it’s nothing but, I want a single fine needle aspiration biopsy done immediately

This call for ‘immediacy’ of the needle biopsy caused some genuine ‘terror’ in that moment for the patient. Unfortunately (perhaps at the time, though in retrospect a ‘good thing’), the procedure could not be scheduled until several days later.

Meanwhile in an alarmed state of an uncertain health status the patient called a women’s health activist for support. She recounted the facts of her encounters and AMC recommendations for follow-up. Upon hearing what played out, an appointment was immediately scheduled with a whole breast imaging (WBI) specialist outside the AMC’s medical staff. Prior to the appointment the whole breast imaging radiologist requested access to AMC’s mammogram and ultrasound imaging to date. The patient then journeyed back into the AMC requesting and obtaining same.

At the WBI center and post scanning the patient was told that of the two suspicious lesions identified by the AMC, neither where malignant. However, the whole breast imaging radiologist made a definitive call that another, deeper lesion not seen on the AMC mammograms or ultrasounds to date, was in fact ‘ductile invasive’ carcinoma.

Patient’s note:

Had I gone through with the recommended needle biopsies of the two suspect lesions, the likely results may have produced a ‘false negative’, with perhaps a return to the routine yearly screening schedule.

Needless to say this is not in the patient’s interest when an undetected malignancy goes untreated for another six or twelve months. [Editors' Note: Clearly an incorrect diagnosis and resulting delay in appropriate care management can not be considered quality nor accountable care].

Now presented with conflicting diagnostic reads of her condition, patient returns to AMC for biopsies ordered by breast surgeon and presents WBI report to invasive radiologist who read it and says:

let’s go do the double core excavation biopsies.

Patient complies.

First lesion is ‘clean’ per radiologist. Second lesion caused some interactions between interventional radiologists centering on location and positional considerations of both breast and shoulder to correctly locate suspect lesion. Patient was not clear, i.e., she trusted the interventional process, as to whether AMC concerned themselves with ‘invasive ductile carcinoma’ call by the non AMC whole breast imaging radiologist.

To fast track forward, post multiple biopsies, and another MRI, the definitive diagnostic decision is delivered ‘you have cancer’ (some eleven days after WBI radiologist delivered the news).

This is one patient’s experience that raise issues on multiple levels, and may not be unique. Here are just some of the operational and system questions the experience raises on the path to accountable care:

  • Who is advocating for the patient when even in enlightened health systems too many of the constituent players remain domiciled in legacy departmental silos?
  • Why is the burden of delivering competent medical opinion outside of a network or health system solely on the patient to ‘make happen?’ Why such ‘data illiquidity?’
  • Who are the parties in interest to remedy systemic failures, i.e., departmental silos not communicating internally in an otherwise reasonably advanced health information technology savvy culture?
  • What role, if any, does the health plan have to re-mediate if not resolve systemic problems adversely impacting care coordination if not quality and outcomes of their ‘members’?
  • Can systems of care and academic systems in particular legitimately discount if not ignore ‘inputs’ provided by out of system participants? For instance, if a department of radiology dismisses whole breast imaging as a valid diagnostic tool, can they toss it aside and leave it solely to the patient to make it part of the diagnostic and treatment consideration process?

There is considerably more to this story. This includes only the breast cancer diagnostic and initial treatment process portion. The next phase will drill into the after treatment continuum and the many gaps in care that currently exist outside of tightly managed integrated delivery systems, and the real world impact this ‘black hole’ has on the patient both from a psycho-social as well as physical health status perspective.

The next blog post will focus on the role of the health plan to acknowledge and remedy apparent gaps in the downstream continuum of care once disclosed. We’ll attempt to frame the concern from both a population management and total health perspective under the triple aim umbrella. Considering the ACOs will assume broad systemic liability for the health status of the members assigned to the ACO all consequential gaps in care will need be remedied if the entity is to reduce readmission risk, and well as minimize the quality and cost consequences of delayed care due to incorrect or misdiagnosis of underlying disease, while restraining the growth rate of healthcare expenditures in an ‘at risk’ and aging population.

ACO Deep Dive Session at this Year’s Health Datapalooza

By Gregg A. Masters, MPH

This just in from the Centers for Medicare and Medicaid Innovation and HDI Forum III:

The CMS Innovation Center is helping plan one session of this two-day event. An ACO “deep dive” will demonstrate how Accountable Care Organizations can make effective use of claims data through innovative software services and analytics. Surgeon and author Atul Gwande will be leading a discussion between the audience and a diverse set of stakeholders from data analysts to a number of the Pioneer ACOs.

‘This year’s event will feature keynote addresses and panels, breakout sessions, apps demos and action beat announcements. Make sure you stop by the Data & Apps Expo to talk with data producers and the developers that use that data to create innovative tools and services to improve the health of individuals and communities. See an overview of the agenda below, and click through to find a detailed schedule of the events on Day 1 and Day 2.’

Thought leader and major disruptor of the health plan gene pool, Mark T. Bertolini, (aka @mtbert), Chairman, CEO & President, Aetna aka, @Aetna, to deliver Day 1 keynote address.

Welcome and opening remarks:

Matt Miller, aka @mattMillerNow, Host, “Left, Right & Center,” NPR (moderator)
Bob Kocher, aka @BobKocher Partner, Venrock (HDI Forum III Co-Chair)
Dick Foster, Venture Partner, Lux Capital (HDI Forum III Co-Chair)

For complete program details, click here.

Accenture: Making the Case for Connected Health

By Gregg A. Masters, MPH

Great timing and contextually rich, Accenture released their report ‘Making the Case for Connected Health’ with some surprising observations to some, including this blogger. For the complete report, click here.

To recap, the major findings include:

  • Connected health is a must. Governments around the world see connected health as a critical and essential means to improve citizens’ access to quality, lower-cost healthcare. Connected health has gained a high level of acceptance, and there is a prevailing view that without a solid connected health platform, it will be difficult to meet today’s—and future—health challenges.
  • Integration is possible. Connected health can and will work with deep and varying underlying industry structures. Different countries have very different provider systems, and these are unlikely to change in the near term. All are fragmented, but in different ways. Healthcare IT connectivity helps bridge this fragmentation to provide better integration.
  • Connected health is on a self-sustaining path. Quality and performance measures require an integrated look at the data. These measures also increase the need for additional information, which, in turn, boosts the need for healthcare IT, and process change to enable such measures.

Via U.S. Ahead of Other Countries in Physician Health IT Adoption at iHealthbeat, we can also note the following key facts:

  • About 62% of U.S. specialty physicians use electronic tools to improve administrative efficiency, compared with the global average of 49%
  • 54% of U.S. primary care physicians use electronic prescribing, compared with a global average of 20%
  • 48% of U.S. physician specialists send orders electronically, compared with a global average of about 36%
  • 38% of U.S. primary care doctors have electronic access to clinical data about patients who have been seen by a different health care provider, compared with a global average of 33%
  • 17% of U.S. physicians have given patients electronic access to their own health data, compared with a global average of 8%.

During a Booz Allen Hamilton webinar titled, Electronic Health Records 2.0: What Does the Future Hold?, Peter Basch, MD, FACP; Medical Director, Ambulatory EHR and Health IT Policy; MedStar Health, quoting the Accenture report remarked on percent of US physicians (vs. global average) using EHRs, HealthIT, e-perscribing, is now ‘..the highest in the world… [followed by laughter, the] I’ll have to change all my slides.’ Entire audio clip here.

The time is now, accountable care is here to stay, health reform legal disposition notwithstanding.

Accountable Care and HiMSS 2012

By Gregg A. Masters, MPH

On the Wednesday, February 15th 2012 broadcast at 11AM Pacific/2PM Eastern, my special guest on the HIMSS 2012 Countdown Series was Vince Kuraitis,  aka @VinceKuraitis, publisher of the ‘e-care Management blog.We spoke on the connection between ‘HIT Platforms and accountable care.’

We’re one week out from the HIMSS 2012 conference in Las Vegas, and the anticipation is palpable. For conference details, click here.

One of the key events I plan on covering via HealthGeek.tv is the eCollaboration Forum on Thursday, February 23rd.

As we debate the pathways to enable the accountable care vision the role of health information technology is at the core of those discussions.

As additional context, you might want to download the free eHealth Initiative survey, see: ‘Support for Accountable Care: Recommended Health IT Infrastructure‘, highlights duly noted by Neil Versel at Interoperable IT Crucial For Accountable Health Organizations.

CLOUD (Consortium for Local Ownership and Use of Data) Inc CEO on ‘N of 1 Accountable Care’

By Gregg A. Masters, MPH

On the Friday, February 10th, 2012 broadcast of ‘This Week in Accountable Care’ I had the pleasure of chatting with Gary Lee Thompson, aka @GaryLeeThompson, and @CLOUDhealth on Twitter.

As the second installment in our HIMSS 2012 countdown to Las Vegas, we spent some time getting to know Gary, understanding both his tech (and legal) background as well ‘the storm’ of 2003 (see: A View from Gary: Survivorship is Not a Phase) when the diagnosis of cancer was presented to he and his wife Maureen, concurrent with her learning she had passed the boards for licensure as an architect to practice in the state of Texas.

Gary is a thought leader who has proposed a vision of a re-fabricated internet, where the ‘you’ and the ‘what’ are contextually connected in real time and wrapped in a dynamic state of ‘you’ rights driven tag access to disparate health information silos.

We discuss his vision and it’s relationship to enabling accountable care. To listen to an archived replay of the broadcast, click here.

For more information on Gary and the consortium, see: ‘CLOUDinc‘.

ACO Summit AM Roundup

We always feel a tad behind the power curve here on the West coast when events begin in the ‘ET’ AM zone circa, in Todd Park’s vernacular, ‘…..at 0 dark hundred.’

Such is the case for the 2nd National ACO Summit which has convened in Washington DC today with many of the names we’ve come to associate with leadership (both thought and on the ground) in the ‘accountable care’ conversation with our without the ‘O’.

See the complete agenda here.

For a hashtag summary courtesy of our friends at the Fox Group, see the recap and Twitter scroller, here.

And the emerging ‘digital footprint’ can be view here.

We’ll stay on top of notable quotes and key themes as they unfold.

Meanwhile my key take away from the AM session is summarized by the following quote from Steve Hester, MD, MBA
Senior Vice President and Chief Medical Officer, Norton Healthcare, Louisville, KY:

‘Change is coming whether we all like it or not..’

 

World Congress Leadership Summit on ACO’s: A Recap

By Gary Baldwin, Health Data Management Blogs

I spent two days last week at the World Congress Leadership Summit on Accountable Care Organizations and my mind is just now recovering. As far as speaker quality goes, this conference (which offered concurrent tracks on ICD-10 and Meaningful Use) was top-notch, with dozens of speakers from hospitals, medical groups, payers, and consulting firms. There was a lot to absorb, but a few recurring themes came through. Here are my Top 10 takeaways from the conference:

1. The End of Fee-for-Service Medicine is Near

Although it has not commanded the media attention of the previously reported end of the world, the demise of productivity-based reimbursement models is imminent, with profound implications for physicians and anyone else working in the industry. Just how imminent? Well, no one offered a specific doomsday date and time, but consider this: According to Paul Markovich, executive vice president of Blue Shield California, the annual premium for one of its HMO policies will rise to $39,000 annually by 2020 if medical inflation continues at the current pace. “The status quo is going to kill us,” he said. And that message was repeated by multiple other participants, providers among them.

2. Current Economics are Unsustainable

You may not like the current iteration of the ACO model (a highly criticized set of proposed rules to be sure), but in one form or another, the industry needs to move to so-called “value-based” purchasing, and do it quickly. “We spend more than we need to and we don’t get good results,” noted Scott Sarren, chief medical officer of Blue Cross Blue Shield of Illinois. “If we fail to reduce costs, our only option left is price controls.”

3. Narrow Timeframe Threatens Federal Program

The health reform law mandates that an ACO program must be in place by January 1. HHS is now digesting comments from a disgruntled industry. The consensus at the conference was that the current ACO proposal is so unwieldy—and risky—that there will be few takers, unless the rules of the game are eased considerably. No one said it, but the federal ACO party may prove to be a giant dud, simply because not very many show up. And make no mistake, this is a program that will need widespread participation to make a dent in the expanding Medicare outlays. Gene Lindsey, CEO of Atrius Health, a Boston consortium of five independent group practices, said his organization is taking a wait and see attitude before jumping in.

There will be some takers for the federal plan, however. James Satterfield, a trustee of the Queens County Medical Society, described the organization’s early efforts to participate—primarily due to a sense of urgency among primary care physicians facing growing expenses and dwindling reimbursements.  “The illusion of being autonomous is gone,” he noted.

4. The Private Sector Will Move on its Own Accord

Faced with the prospects of coping with a tangled federal ACO plan, many in the industry are forging ahead on their own, creating ACO-like arrangements—at the not so tiny risk of running afoul of anti-trust laws. In that sense, Obama’s health reform law—which put teeth (and money) into the federal ACO effort—may already be working. Blue Shield of California has launched three risk-sharing ventures with providers. “This is the private sector’s last chance to demonstrate affordability,” Markovich said. And the Illinois Blues plan has launched an ACO in Chicago with Advocate Health Care, a large hospital system.

5. The EHR is a Foregone Conclusion

Participating in an ACO of any stripe is all but impossible without an EHR. That message underscored multiple presentations. And while the idea is not shocking, the fact that so many speakers now take for granted the technology that has been resisted for so long is telling. Furthermore, the EHR can work, and work well, even in the complex environment of a large, multi-specialty group practice. With 800 physicians, Atrius is fully implemented on its Epic EHR across some 30 sites. “The EHR allows us to function as one large contracting entity,” noted Lindsey, adding that half of its 700,000 patients are being treated under global payment arrangements.

6. Without the Docs, ACOs Go Nowhere

In the ACO world, all eyes will still be focused on physicians. They may…

For complete article, click here.

Gary Baldwin is the Editorial Director for Health Data Management, and has been covering health care since the early 1990s. Prior to rejoining Health Data Management in 2008, he served as technology editor for HealthLeaders Medi for nearly five years.  

Tough Sledding Ahead for the EHR Industry?

Perhaps this exchange best illustrates the clash of culture between the ‘medical boots in the ground’ aka CMIO’s and the EHR industry. The names have been changed to protect the innocent or guilty depending on your perspective.

Cast:

A really smart and justifiably confident EHR engineer, programmer and system architect for a major EHR company with decent market share.

A passionate and ‘has drunk the koolaide’ CMIO (of a modest size East coast, stand-alone non-profit community hospital) of the EHR value proposition, with some rather compelling reservations and real time (garbage in/garbage out) concerns.

Paraphrased narrative over drinks and dinner:

CMIO: Your EHR (generically speaking) is going to kill hospitals like mine!

EHR Dude: Why do you say that?

CMIO: There’s too much unfinished translational work that invariably falls onto my desk as CMIO and therefore the de facto educator and implementer in chief of a program that few physicians want to try to learn let alone work with.

EHR Dude: Well then that’s your problem.

CMIO: No but you don’t understand, it’s killing my hospital and will take us down (i.e., out of service).

EHR Dude: Well, I doubt it. But if that is the case, then so be it…let it sink.

Ok, this oversimplifies and perhaps takes some literary license on the actual narrative, but this is what I basically heard.

I left dinner thinking that, man, isn’t CMIO the customer here? And if so,  shouldn’t EHR dude be listening, and learning from a first person boots on the ground report as an opportunity to make his or the industry’s product better?

What am I missing?

HIMSS Post Script

Head still spining but lots to say on my trip to HIMSS 2011 in ‘Orlando-topia’!

Processing this morning: ‘tough sledding ahead for EHR industry’ a vignette of an overheard conversation between a very smart EHR engineer, and a community hospital CMIO. Crystallizes in my view the ‘dis-connect’ between some in the EHR industry and their ‘medical boots on the ground’ clients.

Also, much to share from the ACO front. I expecially will focus on a comment proffered by Jonathan Bush, of AthenaHealth wherein he posits: ‘Is ACO code for hospitals rolling up docs’ under an integration umbrella.

The Leading from the Future ACO Event, was superb! More to come.