An ACO ‘Deck-o-Topia’ at HiMSS14

By Gregg A. Masters, MPH

This is the fourth year in  row that I have participated in the largest annual gathering of parties in interest to the health informatics ecosystem. From payor to provider to regulator to vendor to the patient and/or consumer of healthcare services, there is always much flare to consider, discard or assimilate. HIMSS14

This year’s gathering is expected to attract somewhere between 30 to 35 thousand attendees. Second only to CES the HiMSS sea of humanity is a distinct strain of conversation to experience.

From one of the tracks that directly appeals to readers of this blog is the track devoted to accountable care and/or ACOs in particular. More later with an individual dive into the more interesting presentations, but the entire decks can be accessed via: Transitioning to Fee-for-Value through ACOs, Care Coordination and Clinical Integration.

Accountable Care, mhealth and the Triple Aim

By Gregg A. Masters, MPH

For those of you following this blog you know I write about ACOs and the emerging accountable care zeitgeist. My lens has been forged by decades of experience in the ‘managed competition’ experiment. For an earlier piece see: Some Context and Perspective on Standing Up the ACO.’ HCFA masthead

The managed competition industry – perhaps more widely known as ‘managed [though more accurately mangled] care’ – can be traced back to it’s regulatory oversight origins via an office in the predecessor agency to CMS, the Health Care Financing Administration (HCFA) titled the ‘Office of Alternative Delivery Systems’ (OADS).

The mission of the OADS was to monitor the then emerging (‘disruptive’) players in the HMO domain but also this little known but ‘HMO lite’ mutation dubbed ‘preferred provider organizations’ (PPOs). The alternative delivery system domain was typically populated by those operators who compensated their contracted network of physicians, hospitals and ancillary providers via other than routine fee for services based payment. Alternative compensation ranged from mere discounts of standard fee schedules to full or partial capitation for physician or even hospital services, thus ADS operators could be arrayed across a continuum of risk assumption.

It is interesting to note that what was then considered ‘alternative’ to prevailing or normalized healthcare financing and delivery is now the new ‘normal’. Yet, we hear more reference to ‘alternative delivery systems’ today as representative by such new age/zeigeist disruptors the likes of certain ACOs, medical homes or even the tapestry of direct, membership, retainer or even ‘concierge’ models of delivery – including hybrids (OneMedical).

So in a way, the first phase of the ‘integration 1.0′ cycle is complete and we’re now embarking on ‘integration 2.0′ using the same terms albeit applied to different vehicles. Instead of HMOs or PPOs, we’re talking about ACOs, medical homes or other care delivery innovations.

Clearly technology – both enterprise and consumer facing – are central to the complex deliverable of the sustainable healthcare ecosystem, yet the preferred ‘chassis’ onto which to stitch if not graft the organizational, governance and operational best practices remain somewhat elusive.  To many digital or mhealth enabled solutions seems to represent a fair amount of rational promise to emerging ACOs.

At the 5th Annual mhealth Summit in a session titled: ‘Mobile Enabling the ACO‘ we’ll here from:

…on the state of the merger between promising digital health technologies and ACO operational fulfillment of certain ACA performance requirements .

The session description and schedule is pasted below:

mobile enabling of ACO

So What’s with the [ACO] Bundled Payment Thing?

By Gregg A. Masters, MPH

It’s interesting to note the more ‘things change’, the more they ‘[seem] to stay the same?’ Let me explain….

In a recent observation by Rob Lazerow featured in the post ‘How Are ACOs Doing‘ the Advisory Board Senior Consultant dubs 2013 as the ‘year of accountable care’. He then goes on to highlight the ‘bundled payment’ program as the center of gravity in ACO market movement since:

It has nearly twice as many provider organizations compared to those participating in the shared savings program. It represents a big spike in experimentation.

Yet, Rob’s newfound gestalt may seem like a bit of back tracking from his previous sentiment as noted earlier via ‘Bundled Payment: A Gateway to Accountable Care? where I engaged him on the subject and value proposition of bundled payment to the ACO movement and holy grail of the triple aim.

So the ‘stay the same’ angle here is more about the herd movement into or out of popular thinking (perhaps even superficial) around ACO strategic issues vs. the granular basing of what we know works, and their real world impediments to local market implementation.

For instance, quite some time ago I penned the following provocative title: ‘Bundled Payment? Lets Start with the ‘RAPERs!’ Unfortunately, I was dead serious then and remain so today, however this bit of granular insight was a tad more than the market wanted to consider then. It received little if any attention and/or discussion, yet it goes to the fundamentals of our ‘healthcare cost conundrum‘. Might it’s reception be different today? Are we really ready to tackle the issues, or will we be content to just keep talking and meeting, with little to nothing changing? We shall see.

HiMSS 2013 Accountable Care Organization RoundUp: Monday March 3rd

By Gregg A. Masters, MPH

Himss 13 LFTF Masthead

We’re only 8 days out from the HiMSS bash in the ‘big easy’ aka ‘NOLA’. We’ve been so engaged in planning the Health Innovation Broadcast Consortium aka @HIBCtv coverage it’s been a challenge to stay on top and share the more worthwhile developments in the ACO space.

So lets detail some of the events that have caught my eye and we’re likely to cover in some fashion. First up and from the ‘specialty program’ department from the Delivering on Value – The Handshake Between Cost & Quality  I’m intrigued by the following trilogy as all address fundamental issues in standing up a viable ACO:

The ‘ACO Encounter: Physician-Lead Perspective

Description: The fastest growth in accountable care organizations is in physician-led ACOs. Gain insights from the experiences of knowledgeable physician-led accountable care initiatives who work with multiple small and medium size practices. **Each ACO Encounter presentation will be provided three times between 1:45 p.m. and 4:45 p.m. Attendees will have the opportunity to rotate though all three encounters during that time frame. Please refer to the attached PDF program for more details.

Speaker: Michael Griffis

Obtaining Quality through New Care Models: Challenge and Promise of ACOs

Description: Hear how to identify and better manage high-risk, high-cost patients, while exploring different care models, such as accountable care organizations, and incentive programs, such as value-based purchasing, to optimize patient care management.

Speaker: Blair Childs

ACO Encounter: Payer Perspective 

Description: Commercial health plans are partnering with providers to build successful accountable care collaborations with their expertise and analytic capabilities. Hear from leading health plans about innovations and strategies around reporting, care coordination, payment models, and analytic tools including risk identification and predictive modeling.

Speaker: Charles D. Kennedy, MD

Note: While much of the attention in ‘ACO-dom’ has rightfully centered around CMS certification of participating entities in the Medicare Shared Savings Program (MSSP), and via the Centers for Medicare and Medicaid Innovation (CMMI) the Pioneer and Advanced Payment model programs, there is a frenetic pace of activity in the commercial markets stoked in part by Aetna, Cigna, United et al, under the banner of ‘accountable care collaborations’ et sequelae. Dr. Kennedy is a principal architect of Aetna’s accountable care solutions group.

We spoke with in ever so briefly here, and look forward to spending some time with him up close and personal in NOLA.

JP Morgan Healthcare Conference 2013

By Gregg A. Masters, MPH

We’re here in the ‘city by the bay’ for the 31st annual assembly of biotech and pharma peeps and the money they seek from the venture capital world. Not exactly my tribe, but my interest was sparked by the generous ‘non profit track’ with many nameplate integrated delivery systems in the strategy and market management conversation.JP Morgan Healthcare Conference

For details, links and some humor on the event including ‘twit’ offered by conference attendees see: JP Morgan Healthcare Conference TweetUp or JP Morgan 31st Annual Healthcare Conference.

Major kudos as JP Morgan is livestreaming portions of the event. This is public but you will need to register on their site.

More later….

Big Data, Little Information, and the ACO Big Picture

By Michael Planchart, Perficient, Inc.

The Journey of a thousand miles towards an ACO begins with one step.
Healthcare organizations are coming to realize that the programs stimulated by the ARRA – HITECH Act, Meaningful Use (MU) and Accountable Care Organizations (ACO), require something that they don’t have in sufficient quantities, the desired type or in the right format: “Data”.

In this post we’re going to focus primarily on the ACO analytics side of things although some of the same principles are applicable to Meaningful Use at its various stages.

The Little Data We Do Have

Historically hospitals have focused on managing their data from the financial perspective. They are very good at submitting claims and receiving the reimbursements, or denials, and reconciling these. They are also very good at dealing with myriad payers which each have unique and complex processes and workflows to embrace. Government payers such as Medicare and Medicaid are very different to deal with because of complex rules that each of them has; Medicaid differs from state to state; private payers also have their disparities. Most healthcare organizations have created value based purchasing strategies that have nothing to envy the mammoth retailers. But all this data generated, stored and mined is similar to that of any other industry vertical. It’s business as usual here.

Hospital organizations have been relying on claims data for most of their financial and operational needs.

The current trend in healthcare is far beyond this type of data. Managing a patient’s health requires relevant clinical data. This is the data that is hundredfold more complex than any other industry has to deal with.

Folks that are, for the first time, entering the Healthcare Information Technology (Health IT) domain are a little perplexed and seem to perceive that we are years behind other domains. This is far from the truth. In the other verticals such as the banking, investment, retail or telecommunications ones, most of the data is of financial, logistic and operational nature. In healthcare we have to deal with this type of data as was indicated and with the other types that are not measurable with fingers alone, or an abacus.

Where’s the BIG Data

Laboratory information results are value and range based (e.g., normal, high, low), or binary (e.g., positive, negative), resulting from the chemical analysis and measurement of specimens (e.g., blood, urine, tissue); anatomical pathology results consist of the same in addition to complex interpretation narratives.

Medicines are discrete units that are being dispensed and administered (e.g., Metformin ER 500 mg tablet, Mupirocin Ointment USP, 2%) but also within a time frame, finite or infinite, and at precise intervals. And to add to the complexity; dosages may vary during the episode of care or an encounter in response to the patient’s reactions; allergies have to be taken into account; medicines may be changed; drug-to-drug interactions are evaluated prior to administering; diet has to be tracked and recorded; follow-up procedures or treatments have to be accounted for.

Imaging results from radiology contain images, discrete data, metadata and non-discrete narratives combined and packaged as a study. The non-discrete narrative is contained in report that is created by the radiologist while “reading” the images and recording into a transcription device or software which is converted from voice to text. A study can contain 1 or hundreds of images; a simple chest x-ray may contain 1-4 images (e.g., Posterior-Anterior (PA), Anterior-Posterior (AP), lateral (LAT)); a CT study may contain as many as 500 images each representing a slice.

We have complex coding systems: ICD-9 (currently migrating to ICD-10) for the classification of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases; LOINC for the classification of laboratory and clinical observations; SNOMED as an organized categorization of clinical terms, codes, synonyms and definitions of diseases, diagnosis and procedures; RxNorm provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software; etc.

Hospitals also have their own reference coding systems that have evolved throughout the years.

When a patient arrives at a provider facility and the clinicians begin with the anamnesis, many events, manual or automated, may start occurring: insurance or Medicare/Medicaid eligibility is verified; laboratory, radiology and pharmacy orders are entered; laboratory and radiology results are generated; medications are ordered, dispensed and administered, sometimes with CPOE and sometimes not; scheduling is processed and resource availability is verified; registration, admission and transfer events are triggered; billing details are validated and recorded. Behind the scenes there are disparate systems “talking” to each other in several healthcare lingos: HL7, X12 and DICOM. Hundreds or thousands of messages containing data are going from here to there and vice-versa. All these messages are sending data that is being consumed by other systems or even other external organizations.

Then, if there is so much data why is there little data?

The answer is simple: an enormous amount of data or information generated that spans from the beginning of a patient’s anamnesis, through the evolution of the episode of care and until the end of the catamnesis, is not being collected, and if it is being collected then it’s being recorded in a format that is inadequate, difficult or impossible to mine (or extract).

But didn’t we just say in one of the above paragraphs that hundreds or thousands of messages containing data are being exchanged during an encounter?

The answer is yes, but the data that is being collected is only the tip of the iceberg of what is required for many of the use cases being envisioned and which are required to manage the population’s health that belong to an ACO.

For example, from the anamnesis the clinician obtains the chief complaint and tons more of information provided entirely by the patient that may have motivated the visit or encounter. The majority of the information being provided by the patient is subject to the interpretation of the physician or the nurse. Have you ever gone to two different doctors with the same ailment and received the same interpretation? I haven’t.

The physician and nursing notes are not being transcribed into the Electronic Health Record (EHR) of the patient mostly because many providers don’t have an Electronic Medical Record (EMR) system. Maybe the provider has an EMR but the EMR doesn’t capture the information in a discrete way. These documents might be scanned and stored in an image format.

You’ve mentioned it a few times, what in the world is an anamnesis? Good question, the anamnesis is the combination of the verbal narration and written information the patient provides initially during the first encounters and it may continue throughout the entire episode of care; and since the care of a patient can depend on other people than him/herself abundant data or information may come from a heteroanamnesis, that is where relatives or caregivers narrate and provide written information about chief complaint, family history, present illness, etc.

Thinking from the End

An ACO requires the following capabilities among many others:

  • Population Health Management (PHM)
  • Chronic Disease Management (CDM)
  • Disease Registries
  • Health Information Exchanges

These capabilities require tons of data or BIG data that should be collected by clinicians and other trained healthcare professionals and not by mere source systems communicating messages between themselves.

Most of the healthcare organizations have a very difficult time knowing what the Average Length of Stay (ALOS) is for their patients at each one of their facilities. Needless to say they believe that a re-admissions management system is something required to operate effectively. Do you have to manage re-admissions or do you just have to count them? You don’t manage re-admissions you avoid them!

How much data do you need to obtain results for these two trivial indicators? All you need is the patient identifying information and the admission and discharge dates for each episode of care. Of course, you could also get fancier and try to obtain the ALOS that corresponds to a particular physician or department. But still, this data is easily obtainable.

On the other hand the capabilities listed above require data that is not easily obtainable since many times it’s not even collected. In order to succeed you would have to determine what data elements would be required for each of the capabilities and then try to map these to the origins or source systems. Not too long ago I performed a mapping for Coronary Artery Disease (CAD) and it was a daunting task. My team and myself had discovered that 80% of the data elements had to be manually abstracted since they were contained almost entirely in scanned notes or even paper notes that had never been scanned.

Yet, thinking from the end and mapping to the source will help you discover the gaps in data that is required for each use case.

The Heterogeneous Curse

Most healthcare organizations choose the “Best of Breed” model for their various systems. What this means is that each application has its own database and typically they don’t share information among each other.

Even those healthcare organizations that have chosen a single vendor for most of their needs face a similar dilemma in that the vendors generally grow their offerings by acquisition of other smaller software companies. The end result is that although the systems are under one vendor’s umbrella they generally implement different technologies and interoperability among them is as challenging as in the “Best of Breed” model.

HL7 messaging, as explained above, has been able to get most of these applications to “talk” to each other. “Talking” alone doesn’t solve the problem of “actionable” data. “Actionable” data is a requirement for many of an ACO’s requirements.

The BIG Challenge Ahead

Getting to “actionable” data is key to overcoming the heterogeneous curse. This is the BIG challenge ahead.

Taking on this challenge one step at a time can help overcome the paralysis.

The most crucial step is creating an Operational Data Store (ODS) and an Atomic Data Store (ADS) from all the available historic data, whether archived or extracted from the source systems databases. Those organizations that have taken this step have been the ones that succeeded with Business Intelligence (BI), Clinical Intelligence (CI) and near real-time use cases.

The ODS/ADS combo will help aggregate the patients data. They will also be the precursors for the Extract, Transform and Load (ETL) layer.
Unfortunately, most hospitals treat the messages that are exchanged by the myriad of systems in a “consume and discard” fashion. Most of the messages navigate through the healthcare system going through a broker or interface engine. These messages get transformed or mapped and are pushed to the consuming systems which ingest the information they need. The messages may stay in the interface engine’s data store for a short period of time; typically between 15 to 30 days before they are deleted.

The next step is fomenting a cultural shift of the clinical staff. Clinicians have been reluctant to be data clerks and many have valid reasons. Fomenting the cultural shift is not changing mindsets of the clinicians. Enabling them with novel technologies to capture a patient’s health status at all critical points of the workflows will be the real game changer. Mobile technology, natural language processing (NLP) and voice recognition should become ubiquitous in the healthcare settings.

Leverage the CCD and other CDA based documents at each point of transfer of care. This requirement alone will be the major force to put in place all the necessary gear to get to an interoperable state.

Indirect requirements will start popping up: data governance will be mandatory, and so will coming up with well-defined terminologies and coding systems. Don’t let these dissuade you since they are all good.

Conclusion

To succeed in the future healthcare paradigm you must start immediately. Take one step at a time, have a BIG strategic picture of the future but act tactically now. You will get there, eventually.

Michael Planchart, aka @theEHRguy is an Health IT Interoperability Consultant, Enterprise Architect for Healthcare IT, Standards Specialist:HL7, DICOM, IHE. Android and iOS Mobile Health Apps designer.

Dave Chase CEO of Avado at Health Datapalooza

By Gregg A. Masters, MPH

In the flurry of activities associated with the Health Data Forum III in Washington, DC aka (‘health datapalooza‘) I managed to corral  Dave Chase aka @ChaseDave in the Exhibition Hall at the DC Convention Center following his presentation at the ACO breakout session.

Amidst the background noise, we hear from Dave about his highlights from the event, a little about Avado and how they serve the interests of developing or operational ACOs.

During the ACO track at Health Datapalooza, there were four categories of software that have emerged as a result of ACOs. Chase argues that one of the new categories will be Patient Relationship Management (PRM) that is a superset of traditional proprietary patient portals tied to a single EHR. The PRM category does more to directly weave the patient into the process in a way that the Pioneer ACOs described.

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.

DC Health Innovation Week: A ‘Triple Aim’ Love In or More Silo’s In the Making?

By Gregg A. Masters, MPH

As we trudge forward into various iterations of what and how ‘accountable care’ strategies can be sensibly configured and locally seeded for Medicare, Medicaid as well as commercial markets, attention is often focused on the ‘necessary’ but ‘not sufficient’ contribution(s) from health information technology (HIT). It is rare that a conversation centered on accountable care or ACOs in particular doesn’t shift to HIT, where EHRs, HIE’s (heath information exchanges) or other data banking or connectivity solutions aren’t a material part of the dialogue. Often posited as the central spine enabling the required coordination and integration essential to accountable care, the technology side of the challenge frequently preempts other issues including physician culture, clinical and financial risk management tolerance and sophistication, or the history of successful physician/hospital joint ventures, in the local market.

Yet in the paradigm shift from volume to value via accountability many are focused on the presumptive return expected from consumer empowerment and electronic health information connectivity. Whether couched as informed choice via up-leveled health literacy, e-patient activism, ‘data liquidity’ or the litany of supportive ‘apps’ including mhealth, wireless or other prevention and wellness oriented platforms, the consumer empowerment movement incentivized by HITECH and further challenged via the triple aim quest are energizing many entrepreneurs, healthcare providers and even regulators.

In June we’ll witness another round of broad based healthcare stakeholder engagement during Health Innovation Week in Washington, D.C. For context, check out Wil Yu’s post on the Healthcare Blog titled: Breaking Down the Process of Innovation: The Value of Community.’

Starting with the Health 2.0 sponsored code-a-thon and [coincidentally] ending with the 3rd Annual National ACO Summit, with HealthCamp DC, Regina Holliday’s ‘The Walking Gallery‘, and the jointly sponsored Institute of Medicine’s and Department of Health Services HDI Forum aka ‘the Health Data Palooza‘, the week will be full of learning, networking and collaboration opportunities.

ACOwatch will be onsite and reporting from several of the venues. Where possible we’ll broadcast recaps, and even livestream all or portions of select events. Minimally you can expect a generous outbound tweetstream via @ACOwatch, ACOalliance or @2healthguru.

Health Reform Readiness Infographic

By Gregg A. Masters, MPH

We all love infographics, right? This one caught my eye today. Kind of a clever snapshot of the crap shoot we’re in relative to the legal and political uncertainty festering in the US today. The original graphic is courtesy of @HITconsultant via his blog here.

Whether this captures the essence of our health reform readiness or not, the survey findings are summarized as follows:

  • Despite intense debate, over 80% of health plans are implementing Healthcare Reform (HCR) initiatives
  • Consumer experience tops the agenda on the 2012 priority list for health plans with a focus on member satisfaction and service
  • 80% of health plans are in the “wait and watch” mode and only in planning stages with their Health Insurance Exchange (HIX) initiative
  • Nearly 40% of health plans are already implementing Accountable Care Organizations (ACOs); more than half are in planning stages