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9 Tech Building Blocks for a CIO's Accountable Care System

Posted by Matthew Smith on Mar 13, 2013 9:28:00 AM

By Daniel J. Marino, President & CEO, Health Directions

Part 3 of a 3-Part Series

ACO, Clinical Integration, CIOThe CIO’s job is to build an IT infrastructure that delivers core functionalities in a way that supports the hospital’s accountable care strategy with regard to physicians, other provider entities, payers and the market. The key to creating an IT system that delivers on hospital strategy is to understand the different components of an accountable care infrastructure.

Following are the nine IT building blocks of an accountable care system, including critical success factors, strengths and weaknesses of different options, typical selection problems, common misconceptions and implementation best practices. CIOs can configure these building blocks to meet any set of strategic needs and position their hospital to function in the world of accountable care.

1. Standards-Based Information Exchange
Hospital IT departments are currently focusing on technical solutions to exchanging data between hospital and ambulatory systems, including ambulatory EMR and practice management systems, hospital EMR systems and other ancillary hospital systems. For CIOs, the important thing is to understand that the goal is not just to exchange data, but to exchange data in a format so that it can be coordinated and accessed across the care continuum. Without standards-based information exchange, healthcare organizations will continue to be data-rich and information-poor.

A basic question is which standard to adopt—Continuity of Care Record (CCR) or Continuity of Care Document (CCD)? The answer depends in part on the capabilities of your application vendors. It also depends on what kind of information you want to exchange and what you want to do with it. Ultimately, that depends on your organization’s clinical and strategic goals.
The CCR format is built upon a limited number of data fields. The benefit of a CCR file is that data is entirely structured, allowing for full exchange and usability by computer systems. The format is also simpler, allowing for easier set-up with a broad range of provider entities. A CCR-based system is well suited for exchanging basic patient snapshots across a wide range of providers.

The CCD format includes structured data fields and the ability to enter “narrative” information. While CCD is more complex and does not offer fully structured data, it is also better suited to managing the huge amount of information that currently exists on paper. CCD may be the best option for rich information exchange between providers that have ambitious goals for care management.

Existing systems are also a consideration. What exchange platforms are currently in use within your hospital? What is being used by community providers? How will this information be used to support clinically integrated care? The answers to these questions are the foundation for building a true patient longitudinal record.

2. Agnostic Application Strategy
Since the goal is connectivity, an effective accountable care infrastructure will need to be vendor-agnostic. All applications must be able to interface with other systems within the network. From a planning point of view, there are two pitfalls:

  • One danger is presented by IT applications promoted by individual hospital departments or community provider organizations. For example, say the medical oncology department advocates a particular software package for managing infusions. If that system does not interface with other applications such as the pharmacy system or the acute EMR, then interoperability cannot be achieved. The software may be a great infusion management solution, but if it does not support clinical integration around shared data, true coordinated care will be a challenge. The overall need for full data integration takes precedence.
  • The second pitfall is the danger inherent in an enterprise solution. There are several very good integrated solutions available for hospital and ambulatory information systems. However, some of these enterprise systems do not work well with other applications. Connections may be possible, but the preference is staying within the platform. Overall, integrated solutions offer many benefits such as strong core connectivity, and they can make implementation easier. Again, however, if the system prevents full clinical integration and coordinated care management, it will undermine the goal of accountable care. CIOs need to make sure any enterprise solution allows for full connectivity—or negotiate within the vendor agreement that the system will allow for an efficient exchange of information with applications outside the platform.

3. Interoperability
Once information systems have a common language (the exchange standard) and the ability to be heard by each other (agnostic applications), you need to decide what they will say to each other. In concrete terms, decisions need to be made about what structured data will be extracted from which systems, where the data will go and how it will be used.

This will largely involve mapping data from hospital applications into the ambulatory EMR. For example, when a heart failure patient goes to the hospital lab for a BNP test, what will happen to that clinical data element? It must flow into the EMR, but where in the patient record? The answer depends on the network’s accountable care strategy and the needs of physician users. Multiply this example across the full range of possible data elements and it becomes clear that mapping data to achieve interoperability is a huge undertaking.

Many EMR systems come pre-loaded with structured data sets, but hospital IT leaders should be wary of these “out of the box” interoperability solutions. Generic data sets do not work well in most situations, because they generally focus on regulatory requirements and are not individualized to the needs and strategy of the organization.

4. Patient Longitudinal Record
Under traditional paper medical records systems, information sharing involves printing or copying records and physically sending them to another provider. When developing an electronic records system, one pitfall is the temptation to see the EMR as simply a digitized version of the traditional process. Attention is focused on exchanging data between different users. Information sharing is important, but hospital CIOs also need to focus on the underlying goal of EMR, which is to create a longitudinal patient record—one that consolidates and organizes patient health information from every provider into a systematically organized composite record.

A patient longitudinal record is critical to accountable care because it provides physicians with a comprehensive view of the patient’s health history, tests and services. It is seen as an antidote to “episodic care,” in which interventions are based largely on provider specialty with limited knowledge of the patient’s total condition. A longitudinal record enables physicians to manage the patient’s total care experience across acute, ambulatory and long-term care systems, and between multiple provider specialty settings. The driving force is to integrate and harmonize clinical data for providers. For instance, an effective patient record will organize a patient’s name with their complete list of medications from all providers. Beyond that, it will organize brand name medications with generic equivalents, helping to drive efficient clinical decision making at the point of care.

5. Clinical Decision Support Systems
Providing physicians with comprehensive patient information is not the only goal of an EMR system. Healthcare leaders expect EMR to actively drive better care through Clinical Decision Support Systems (CDSS)—automated alerts and reminders that support medical decision making at the point of care. CDSS functions can include alerts for adverse drug interactions, drug allergy reactions and potentially redundant tests; reminders for preventive care services and labs by diagnosis; and automated assistance with prescriptions and dosing.
Most EMR software packages include clinical alert functionalities; but again, using “out of the box” settings and pre-programs is not advisable. Physicians, both employed and community-based, need to lead the process of designing CDSS alerts and reminders based on agreed-upon care protocols—and care protocols must be based on the organization’s specific strategies for achieving accountable care.

For instance, say a hospital/physician network decides to focus on coronary artery disease (CAD) as one of the cornerstones of its accountable care strategy. Successfully managing this condition can reduce overall costs significantly by reducing readmissions and preventing complications like heart failure and arrhythmia. Based on this goal, physicians and other clinical leaders will establish a number of diagnostic and interventional protocols for optimal CAD care. As part of this initiative, the EMR will be configured with supporting CDSS functionalities, such as reminders for periodic blood tests and alerts for test results that fall outside agreed-upon ranges. Alerts could also be configured to flag results and indications that suggest the need for imaging studies or EKGs.

6. Clinical Data Repository
An EMR system is a powerful tool, but it is not the only data management system required for accountable care. This is a source of confusion for many. EMR is a tool for capturing, retrieving and working with patient information at the point of care. It does not allow users to manage the care of a large patient population. To create this capability, an organization needs a clinical data repository (CDR).

A CDR is a database that stores information entered from a variety of provider systems. The database includes structured data elements and standardized data sets for coordinating de-identified patient information, and it offers analytic capabilities that allow clinical data reporting. CDRs enable two processes that are critical to allowing an organization to function as an accountable care provider:

  • First, the CDR creates an infrastructure for joint clinical decision making. Physicians and other clinical leaders can use CDR reports to identify problems with clinical processes and outcomes, develop solutions and track improvement. A powerful CDR will allow clinicians to monitor and improve clinical performance by disease, age group, risk factors, clinical intervention and many other parameters. It also allows hospital and clinical care leaders to help individual providers identify and adopt better clinical practices.
  • Second, a CDR allows an organization to report information required under accountable care payment systems. The structured database is the means for capturing and validating clinical performance and getting paid for attaining performance goals. This will become especially important for organizations that enter into full risk contracts with payers.

7. Personal Health Record Integration
Patient Health Record (PHR) technology is not as well developed as EMRs, and there are a lot of questions about how patients and provider organizations will use it. However, planning for a PHR system cannot be pushed off to the indefinite future. Medicare ACO regulations specify that patients must have electronic links to their health information, and expectations for patient connectivity will increase. Even under less stringent commercial accountable care programs, organizations recognize a strong need to engage patients in their care and use electronic technology to involve individuals in disease management efforts.

No matter what the current state of an organization’s accountable care program, CIOs need to start creating plans for incorporating a PHR system into an accountable care infrastructure. Technically, the issue is establishing the interfaces to get PHR data feeding into ambulatory EMR, acute EMR and patient registration systems. More important, the organization needs to make decisions about what information will be captured in a PHR and how it will be used.
Again, organizational strategy is the driver. Begin by building the PHR around the organization’s core accountable care projects. For example, if the organization is beginning with a clinical integration effort around hypertension, the first step might be to allow patients to log medication use and home blood pressure readings within the PHR and receive periodic reminders about diet, exercise and stress management.

8. Business Intelligence Capabilities
A key mechanism of the accountable care model is holding providers financially responsible for spending, at least within certain parameters. Given that fact, clinical information systems and traditional business information systems are not enough for supporting accountable care. Organizations need to develop robust business intelligence capabilities that allow leaders to manage the financial side of care proactively.

A business intelligence system capable of supporting accountable care will include a data warehouse system with versatile analytical tools. The system will need to incorporate data from hospital financial information systems and physician practice management systems and fold in data from the CDR.

The functional objective of the system is to allow multi-dimensional reporting that encompasses physician and hospital services, patient clinical data, and patient claims data. The immediate goal is to be able to tie clinical outcomes to claims data to identify the cost of care for various diagnoses. The ultimate goal is to use the business intelligence system to identify opportunities to reduce waste, reduce spending and improve operational efficiency and leverage those improvements financially under accountable care contracts.

9. Health Information Exchange
Many healthcare leaders think of a Health Information Exchange (HIE) as an interface engine. This is only partially true. An interface engine transmits data points from system A to system B (for example, diagnostic results from the lab system to the physician EMR). An HIE allows for much more robust connectivity, linking all systems within a community, including internal hospital systems and independent provider systems. An HIE captures outcomes data and organizes patient information across all participating entities. More importantly, it allows information to be exchanged in a federated or “open access” model in which organizations can share or protect information selectively.

How should the IT department plan and design an HIE infrastructure? Once more, CIOs need to make these decisions in the context of organizational strategy. A hospital that intends to lead an accountable care initiative should consider developing its own private HIE so it can determine what data is collected and shared. A community hospital that simply wants to keep up with the industry should examine the possibility of connecting with one of the many state or regional HIE initiatives being developed. Another issue is market strategy. Decisions about an HIE should be aligned with the organization’s service area schema, physician integration strategy and any plans for market expansion.

Staying Focused
In working with all these building blocks, the main point is to stay focused on the basic goals. Look at interface design in light of the need to create information that will help the organization manage and control costs and improve quality. Make system selection choices based on the need to provide comprehensive patient information at the point of care, creating a true patient longitudinal record. Most of all, make sure all decisions about specific applications and overall interoperability are driven by a physician-hospital leadership governance body that has ownership of the hospital’s total accountable care strategy.

Ultimately, the definition of a high-performing IT infrastructure is one that helps the hospital achieve its goals for collaborating with specific provider organizations, improving outcomes for specific patient populations and positioning the organization for success within the ever-changing world of accountable care.

Electronic Health Records EHR Assessment

Topics: ACO, Clinical Integration, CIO, HIT, Health IT, Accountable Care Organizations, Clinical Care, Hospital Technology, IT, Strategy, Strategic Health Care

Five Functional Requirements CIOs Need to Support Accountable Care

Posted by Matthew Smith on Mar 11, 2013 6:07:00 PM

By Daniel J. Marino, President & CEO, Health Directions

Part 2 of a 3-Part Series

ACO, Accountable Care OrganizationTaken together, the demand for cost control and quality improvement, trends in new technology, and developments in the payer landscape are pointing toward five functional requirements of an accountable care IT infrastructure. To support an accountable care enterprise, IT systems must enable providers and administrative leaders to:

  1. Coordinate patient care across multiple settings.Experts believe the lack of coordination between caregivers is responsible for a large portion of excessive costs. Poorly coordinated care leads to redundant services (such as duplicative diagnostics), medical errors (leading to additional costs) and poor overall care for patients with chronic conditions. The IT infrastructure for an accountable care initiative will need to enable strong coordination of services via information sharing between primary care physicians, specialists, hospital-based caregivers (including the emergency department), diagnostic facilities/departments, laboratories and others.
  2. Systematically improve quality and patient outcomes. There are many opportunities to improve patient care by adhering to existing evidence-based guidelines. Additional gains can be achieved by improving efficiency and implementing systems to measure, track and improve quality and outcomes. Accountable care IT systems will support providers by capturing structured clinical data, helping them adopt evidence-based medicine and incorporating clinical care plans to enable provider organizations to manage quality data for entire patient populations.
  3. Systematically reduce costs and utilization. As with clinical improvement, gains in cost control and efficiency can be achieved by reducing redundant processes and using data analysis to identify savings opportunities. The IT infrastructure for an accountable care initiative will support adherence to efficient clinical and administrative processes and enable financial leaders to use data to identify the cost of care and improve financial performance.
  4. Incorporate patients in the information loop. Patient compliance is a major obstacle to effectively managing the cost of chronic disease and improving clinical outcomes. Effective IT systems will support accountable care efforts by enhancing patient communication, engagement and monitoring. For instance, clinical outcome tracking around chronic disease management will enable organizations to create patient-focused clinical outreach programs designed to encourage patient compliance.
  5. Identify and enhance managed clinical value. First-generation accountable care initiatives are concentrating on securing additional revenue from government and commercial shared savings programs. Second-generation initiatives will work to tie clinical outcomes to the cost of delivery of care with the goal of negotiating performance-based managed care contracts. To support this goal, accountable care IT systems must develop increasingly powerful capabilities for storing, mapping and analyzing clinical and claims data from the entire range of clinical and administrative systems.

Hospital CIOs can significantly narrow the scope of IT planning by focusing on the five functional requirements of an accountable care infrastructure. However, these functional objectives do not answer every question about IT design. CIOs still have the challenge of creating an infrastructure that supports the hospital’s specific goals and tactics. The ultimate decision parameter in the IT development process is the hospital’s unique accountable care strategy.

Basic questions include:

  • Will your organization lead an accountable care enterprise or participate in someone else’s? The answer will determine how you manage connectivity and create data management capabilities.
  • Which other entities will the accountable care enterprise interact with and how? The further the network reaches, the greater attention you will have to pay to interoperability issues.
  • What is the hospital’s model for collaborating with physicians? Depending on whether providers are organizing as an integrated delivery network (IDN), a physician-hospital organization (PHO), an independent practice association (IPA) or some other structure, you will need to take a different approach to coordinating EMR systems. This decision will also drive an organization’s hospital and physician integration strategy.
  • What governance model is in place to help drive decision making? Since working toward accountable care requires building on defined strategies, a strong physician-hospital leadership governance model is critical to providing direction and support for IT decisions.

The CIO’s job is to build an IT infrastructure that delivers core functionalities in a way that supports the hospital’s accountable care strategy with regard to physicians, other provider entities, payers and the market. The key to creating an IT system that delivers on hospital strategy is to understand the different components of an accountable care infrastructure.

Clinical Integration, CI, Physician Alignment

Topics: ACO, Clinical Integration, CIO, Accountable Care Organizations, Patient Experience, Hospital Technology, IT, hospital consulting

Infographic: Using HealthIT More Effectively

Posted by Matthew Smith on Oct 23, 2012 1:07:00 PM

This HealthIT infographic, created by IOM, emphasizes that although recent advances in healthcare have been made, the U.S. healthcare system has far to go. Using technology, what’s possible for healthcare? How can we:

  • Use Information Technology More Effectively
  • Create Systems to Manage Complexity
  • Make Health Care Safer
  • Improve Transparency
  • Promote Teamwork & Communication
  • Partner With Patients
  • Decrease Waste & Increase Efficiency

What's Possible with Healthcare? 7 Goals for Healthcare Disruption

Topics: HealthIT, Infographic, Physician Practice Solutions, Patient Satisfaction, Hospital Technology, IT, Healthcare Infographics

9 Tech Building Blocks for a CIO's Accountable Care System

Posted by Matthew Smith on Jul 26, 2012 10:25:00 AM

By Daniel J. Marino, President & CEO, Health Directions

Part 3 of a 3-Part Series

acoThe CIO’s job is to build an IT infrastructure that delivers core functionalities in a way that supports the hospital’s accountable care strategy with regard to physicians, other provider entities, payers and the market. The key to creating an IT system that delivers on hospital strategy is to understand the different components of an accountable care infrastructure.

Following are the nine IT building blocks of an accountable care system, including critical success factors, strengths and weaknesses of different options, typical selection problems, common misconceptions and implementation best practices. CIOs can configure these building blocks to meet any set of strategic needs and position their hospital to function in the world of accountable care.

1. Standards-Based Information Exchange
Hospital IT departments are currently focusing on technical solutions to exchanging data between hospital and ambulatory systems, including ambulatory EMR and practice management systems, hospital EMR systems and other ancillary hospital systems. For CIOs, the important thing is to understand that the goal is not just to exchange data, but to exchange data in a format so that it can be coordinated and accessed across the care continuum. Without standards-based information exchange, healthcare organizations will continue to be data-rich and information-poor.

A basic question is which standard to adopt—Continuity of Care Record (CCR) or Continuity of Care Document (CCD)? The answer depends in part on the capabilities of your application vendors. It also depends on what kind of information you want to exchange and what you want to do with it. Ultimately, that depends on your organization’s clinical and strategic goals.
The CCR format is built upon a limited number of data fields. The benefit of a CCR file is that data is entirely structured, allowing for full exchange and usability by computer systems. The format is also simpler, allowing for easier set-up with a broad range of provider entities. A CCR-based system is well suited for exchanging basic patient snapshots across a wide range of providers.

The CCD format includes structured data fields and the ability to enter “narrative” information. While CCD is more complex and does not offer fully structured data, it is also better suited to managing the huge amount of information that currently exists on paper. CCD may be the best option for rich information exchange between providers that have ambitious goals for care management.

Existing systems are also a consideration. What exchange platforms are currently in use within your hospital? What is being used by community providers? How will this information be used to support clinically integrated care? The answers to these questions are the foundation for building a true patient longitudinal record.

2. Agnostic Application Strategy
Since the goal is connectivity, an effective accountable care infrastructure will need to be vendor-agnostic. All applications must be able to interface with other systems within the network. From a planning point of view, there are two pitfalls:

  • One danger is presented by IT applications promoted by individual hospital departments or community provider organizations. For example, say the medical oncology department advocates a particular software package for managing infusions. If that system does not interface with other applications such as the pharmacy system or the acute EMR, then interoperability cannot be achieved. The software may be a great infusion management solution, but if it does not support clinical integration around shared data, true coordinated care will be a challenge. The overall need for full data integration takes precedence.
  • The second pitfall is the danger inherent in an enterprise solution. There are several very good integrated solutions available for hospital and ambulatory information systems. However, some of these enterprise systems do not work well with other applications. Connections may be possible, but the preference is staying within the platform. Overall, integrated solutions offer many benefits such as strong core connectivity, and they can make implementation easier. Again, however, if the system prevents full clinical integration and coordinated care management, it will undermine the goal of accountable care. CIOs need to make sure any enterprise solution allows for full connectivity—or negotiate within the vendor agreement that the system will allow for an efficient exchange of information with applications outside the platform.

3. Interoperability
Once information systems have a common language (the exchange standard) and the ability to be heard by each other (agnostic applications), you need to decide what they will say to each other. In concrete terms, decisions need to be made about what structured data will be extracted from which systems, where the data will go and how it will be used.

This will largely involve mapping data from hospital applications into the ambulatory EMR. For example, when a heart failure patient goes to the hospital lab for a BNP test, what will happen to that clinical data element? It must flow into the EMR, but where in the patient record? The answer depends on the network’s accountable care strategy and the needs of physician users. Multiply this example across the full range of possible data elements and it becomes clear that mapping data to achieve interoperability is a huge undertaking.

Many EMR systems come pre-loaded with structured data sets, but hospital IT leaders should be wary of these “out of the box” interoperability solutions. Generic data sets do not work well in most situations, because they generally focus on regulatory requirements and are not individualized to the needs and strategy of the organization.

4. Patient Longitudinal Record
Under traditional paper medical records systems, information sharing involves printing or copying records and physically sending them to another provider. When developing an electronic records system, one pitfall is the temptation to see the EMR as simply a digitized version of the traditional process. Attention is focused on exchanging data between different users. Information sharing is important, but hospital CIOs also need to focus on the underlying goal of EMR, which is to create a longitudinal patient record—one that consolidates and organizes patient health information from every provider into a systematically organized composite record.

A patient longitudinal record is critical to accountable care because it provides physicians with a comprehensive view of the patient’s health history, tests and services. It is seen as an antidote to “episodic care,” in which interventions are based largely on provider specialty with limited knowledge of the patient’s total condition. A longitudinal record enables physicians to manage the patient’s total care experience across acute, ambulatory and long-term care systems, and between multiple provider specialty settings. The driving force is to integrate and harmonize clinical data for providers. For instance, an effective patient record will organize a patient’s name with their complete list of medications from all providers. Beyond that, it will organize brand name medications with generic equivalents, helping to drive efficient clinical decision making at the point of care.

5. Clinical Decision Support Systems
Providing physicians with comprehensive patient information is not the only goal of an EMR system. Healthcare leaders expect EMR to actively drive better care through Clinical Decision Support Systems (CDSS)—automated alerts and reminders that support medical decision making at the point of care. CDSS functions can include alerts for adverse drug interactions, drug allergy reactions and potentially redundant tests; reminders for preventive care services and labs by diagnosis; and automated assistance with prescriptions and dosing.
Most EMR software packages include clinical alert functionalities; but again, using “out of the box” settings and pre-programs is not advisable. Physicians, both employed and community-based, need to lead the process of designing CDSS alerts and reminders based on agreed-upon care protocols—and care protocols must be based on the organization’s specific strategies for achieving accountable care.

For instance, say a hospital/physician network decides to focus on coronary artery disease (CAD) as one of the cornerstones of its accountable care strategy. Successfully managing this condition can reduce overall costs significantly by reducing readmissions and preventing complications like heart failure and arrhythmia. Based on this goal, physicians and other clinical leaders will establish a number of diagnostic and interventional protocols for optimal CAD care. As part of this initiative, the EMR will be configured with supporting CDSS functionalities, such as reminders for periodic blood tests and alerts for test results that fall outside agreed-upon ranges. Alerts could also be configured to flag results and indications that suggest the need for imaging studies or EKGs.

6. Clinical Data Repository
An EMR system is a powerful tool, but it is not the only data management system required for accountable care. This is a source of confusion for many. EMR is a tool for capturing, retrieving and working with patient information at the point of care. It does not allow users to manage the care of a large patient population. To create this capability, an organization needs a clinical data repository (CDR).

A CDR is a database that stores information entered from a variety of provider systems. The database includes structured data elements and standardized data sets for coordinating de-identified patient information, and it offers analytic capabilities that allow clinical data reporting. CDRs enable two processes that are critical to allowing an organization to function as an accountable care provider:

  • First, the CDR creates an infrastructure for joint clinical decision making. Physicians and other clinical leaders can use CDR reports to identify problems with clinical processes and outcomes, develop solutions and track improvement. A powerful CDR will allow clinicians to monitor and improve clinical performance by disease, age group, risk factors, clinical intervention and many other parameters. It also allows hospital and clinical care leaders to help individual providers identify and adopt better clinical practices.
  • Second, a CDR allows an organization to report information required under accountable care payment systems. The structured database is the means for capturing and validating clinical performance and getting paid for attaining performance goals. This will become especially important for organizations that enter into full risk contracts with payers.

7. Personal Health Record Integration
Patient Health Record (PHR) technology is not as well developed as EMRs, and there are a lot of questions about how patients and provider organizations will use it. However, planning for a PHR system cannot be pushed off to the indefinite future. Medicare ACO regulations specify that patients must have electronic links to their health information, and expectations for patient connectivity will increase. Even under less stringent commercial accountable care programs, organizations recognize a strong need to engage patients in their care and use electronic technology to involve individuals in disease management efforts.

No matter what the current state of an organization’s accountable care program, CIOs need to start creating plans for incorporating a PHR system into an accountable care infrastructure. Technically, the issue is establishing the interfaces to get PHR data feeding into ambulatory EMR, acute EMR and patient registration systems. More important, the organization needs to make decisions about what information will be captured in a PHR and how it will be used.
Again, organizational strategy is the driver. Begin by building the PHR around the organization’s core accountable care projects. For example, if the organization is beginning with a clinical integration effort around hypertension, the first step might be to allow patients to log medication use and home blood pressure readings within the PHR and receive periodic reminders about diet, exercise and stress management.

8. Business Intelligence Capabilities
A key mechanism of the accountable care model is holding providers financially responsible for spending, at least within certain parameters. Given that fact, clinical information systems and traditional business information systems are not enough for supporting accountable care. Organizations need to develop robust business intelligence capabilities that allow leaders to manage the financial side of care proactively.

A business intelligence system capable of supporting accountable care will include a data warehouse system with versatile analytical tools. The system will need to incorporate data from hospital financial information systems and physician practice management systems and fold in data from the CDR.

The functional objective of the system is to allow multi-dimensional reporting that encompasses physician and hospital services, patient clinical data, and patient claims data. The immediate goal is to be able to tie clinical outcomes to claims data to identify the cost of care for various diagnoses. The ultimate goal is to use the business intelligence system to identify opportunities to reduce waste, reduce spending and improve operational efficiency and leverage those improvements financially under accountable care contracts.

9. Health Information Exchange
Many healthcare leaders think of a Health Information Exchange (HIE) as an interface engine. This is only partially true. An interface engine transmits data points from system A to system B (for example, diagnostic results from the lab system to the physician EMR). An HIE allows for much more robust connectivity, linking all systems within a community, including internal hospital systems and independent provider systems. An HIE captures outcomes data and organizes patient information across all participating entities. More importantly, it allows information to be exchanged in a federated or “open access” model in which organizations can share or protect information selectively.

How should the IT department plan and design an HIE infrastructure? Once more, CIOs need to make these decisions in the context of organizational strategy. A hospital that intends to lead an accountable care initiative should consider developing its own private HIE so it can determine what data is collected and shared. A community hospital that simply wants to keep up with the industry should examine the possibility of connecting with one of the many state or regional HIE initiatives being developed. Another issue is market strategy. Decisions about an HIE should be aligned with the organization’s service area schema, physician integration strategy and any plans for market expansion.

Staying Focused
In working with all these building blocks, the main point is to stay focused on the basic goals. Look at interface design in light of the need to create information that will help the organization manage and control costs and improve quality. Make system selection choices based on the need to provide comprehensive patient information at the point of care, creating a true patient longitudinal record. Most of all, make sure all decisions about specific applications and overall interoperability are driven by a physician-hospital leadership governance body that has ownership of the hospital’s total accountable care strategy.


Ultimately, the definition of a high-performing IT infrastructure is one that helps the hospital achieve its goals for collaborating with specific provider organizations, improving outcomes for specific patient populations and positioning the organization for success within the ever-changing world of accountable care.

Topics: ACO, Clinical Integration, CIO, HIT, Accountable Care Organizations, Clinical Care, Hospital Technology, IT, Strategy, Strategic Health Care

5 Functional Requirements CIOs Need to Support Accountable Care

Posted by Matthew Smith on Jul 25, 2012 9:49:00 AM

By Daniel J. Marino, President & CEO, Health Directions

Part 2 of a 3-Part Series

Accountable CareTaken together, the demand for cost control and quality improvement, trends in new technology, and developments in the payer landscape are pointing toward five functional requirements of an accountable care IT infrastructure. To support an accountable care enterprise, IT systems must enable providers and administrative leaders to:

  1. Coordinate patient care across multiple settings. Experts believe the lack of coordination between caregivers is responsible for a large portion of excessive costs. Poorly coordinated care leads to redundant services (such as duplicative diagnostics), medical errors (leading to additional costs) and poor overall care for patients with chronic conditions. The IT infrastructure for an accountable care initiative will need to enable strong coordination of services via information sharing between primary care physicians, specialists, hospital-based caregivers (including the emergency department), diagnostic facilities/departments, laboratories and others.
  2. Systematically improve quality and patient outcomes. There are many opportunities to improve patient care by adhering to existing evidence-based guidelines. Additional gains can be achieved by improving efficiency and implementing systems to measure, track and improve quality and outcomes. Accountable care IT systems will support providers by capturing structured clinical data, helping them adopt evidence-based medicine and incorporating clinical care plans to enable provider organizations to manage quality data for entire patient populations.
  3. Systematically reduce costs and utilization. As with clinical improvement, gains in cost control and efficiency can be achieved by reducing redundant processes and using data analysis to identify savings opportunities. The IT infrastructure for an accountable care initiative will support adherence to efficient clinical and administrative processes and enable financial leaders to use data to identify the cost of care and improve financial performance.
  4. Incorporate patients in the information loop. Patient compliance is a major obstacle to effectively managing the cost of chronic disease and improving clinical outcomes. Effective IT systems will support accountable care efforts by enhancing patient communication, engagement and monitoring. For instance, clinical outcome tracking around chronic disease management will enable organizations to create patient-focused clinical outreach programs designed to encourage patient compliance.
  5. Identify and enhance managed clinical value. First-generation accountable care initiatives are concentrating on securing additional revenue from government and commercial shared savings programs. Second-generation initiatives will work to tie clinical outcomes to the cost of delivery of care with the goal of negotiating performance-based managed care contracts. To support this goal, accountable care IT systems must develop increasingly powerful capabilities for storing, mapping and analyzing clinical and claims data from the entire range of clinical and administrative systems.

Hospital CIOs can significantly narrow the scope of IT planning by focusing on the five functional requirements of an accountable care infrastructure. However, these functional objectives do not answer every question about IT design. CIOs still have the challenge of creating an infrastructure that supports the hospital’s specific goals and tactics. The ultimate decision parameter in the IT development process is the hospital’s unique accountable care strategy.

Basic questions include:

  • Will your organization lead an accountable care enterprise or participate in someone else’s? The answer will determine how you manage connectivity and create data management capabilities.
  • Which other entities will the accountable care enterprise interact with and how? The further the network reaches, the greater attention you will have to pay to interoperability issues.
  • What is the hospital’s model for collaborating with physicians? Depending on whether providers are organizing as an integrated delivery network (IDN), a physician-hospital organization (PHO), an independent practice association (IPA) or some other structure, you will need to take a different approach to coordinating EMR systems. This decision will also drive an organization’s hospital and physician integration strategy.
  • What governance model is in place to help drive decision making? Since working toward accountable care requires building on defined strategies, a strong physician-hospital leadership governance model is critical to providing direction and support for IT decisions.

The CIO’s job is to build an IT infrastructure that delivers core functionalities in a way that supports the hospital’s accountable care strategy with regard to physicians, other provider entities, payers and the market. The key to creating an IT system that delivers on hospital strategy is to understand the different components of an accountable care infrastructure.

Next Blog Post: 9 Tech Building Blocks for ACOs

Topics: ACO, Clinical Integration, CIO, Accountable Care Organizations, Patient Experience, Hospital Technology, IT, hospital consulting

5 Stages of Successful EHR Implementation

Posted by Matthew Smith on Jul 6, 2012 1:30:00 PM

EHR1 resized 600Regardless of the system a health care provider chooses, there generally are five stages of EHR implementation. To minimize starts-and-stops and practice down-time, Health Directions relies on these five stages to help clients achieve maximum success with their EHR launch. 

Phase 1: Discovery & Selection.

This stage—which typically lasts one to three months—begins when the provider decides to move forward with an EHR. This phase includes conducting research on various options and scheduling demonstrations.

Best practices suggest establishinig EHR committees with providers and staff members, or designate “champions,” staff members charged with coordinating and communicating the task.

An electronic medical record is a clinical system. So, it is very important that the clinical staff (nursing staff and medical assistants) be involved because the workflows on how they see patients are going to change slightly. Secondly, it might be beneficial to involve a representative from the front officeor somebody from the business office because some of those components will overlap with the EHR.

Also during this initial phase, the provider should develop a request for proposal (RFP) based on specific criteria and determine the total cost of ownership and the impact on your revenue cycle and collections.

Phase 2: Negotiating & Executing the Agreement

Negotiating and reviewing the contract, as well as having an attorney review the agreement, should take about a month.

Phase 3: System Installation and Build

This stage takes from one to two months and includes: 

  • Installing and configuring hardware and EMR system software; 
  • Initiating the system build (clinical and business components); 
  • Redesigning business and clinical workflows for optimal outcomes; 
  • Developing a data migration plan (to determine what will be entered as structured data versus what information will be scanned); 
  • Building interfaces to other required systems; 
  • Reviewing federally designated “meaningful use” criteria and building in those measures.

Phase 4: System Training and Going Live

This stage will typically take about a month. Providers should plan to reduce their patient schedules by half for about two-to-three-weeks while the system goes live.

Also, best practices suggest to arrange to have the EHR trainer on site for support for the duration of the initial "go-live.".

Phase 5: System Optimization

Monitoring the practice’s progress toward “meaningful use” measures is an ongoing process. Just like anything else, once you learn something, it is hard to retain all of it and put it into use. Users probably only retain about 70 percent of that knowledge (learned) during the training session. After a practice uses the new system for about a month, the trainer should return for a reassessment, to make sure users are optimizing the functionality of the system.

For additional information and case studies on Health Directions' Healthcare Information Technology Strategy (H.I.T.), please visit our H.I.T. section of our website.

Don't miss a chance for a compimentary Health Directions EHR Optimization Assessment. Simply click the button, below, and share your contact information with us. A Health Directions consultant will be in touch shortly.

Topics: EHR, EMR, Meaningful Use, HIT, Practice Management, Medical Practice, Hospital Technology, IT

Avoiding Physician Backlash: 7 Tips Toward a Successful EHR Rollout

Posted by Matthew Smith on Jul 3, 2012 9:13:00 AM

Hospital Information System6 resized 600Nationwide, hospitals are aggresively acquiring physicians and creating tighter affiliations with physician groups. Building a strong physician network is always difficult, but the challenge is even greater when it is combined with an electronic health record rollout — a necessary move that will allow the partners to share information and take advantage of new payment initiatives.

Implementing a new ambulatory EHR system often will disrupt practice workflow, impair physician productivity and affect physician income. But when a hospital is providing the system, cultural and political issues come into play that can damage or kill relationships. For many hospitals, the EHR rollout creates a physician backlash just when the integration strategy is getting off the ground.How can a hospital mitigate the risks of implementing an ambulatory EHR system? The following seven steps will help minimize conflict, contain costs and increase your chance of a successful rollout.

1. Form a Multi-stakeholder Governance Team

Some hospitals treat an EHR implementation as just another information technology project. Information technology staff members lead the system selection and installation process, executives take a hands-off approach, and physicians are relegated to the role of "receivers." This approach does not work well with electronic health records.

EHR use has a huge impact on physician practice as well as hospital strategy and finance. For that reason, a governance team that includes hospital executives and physician leaders must direct the EHR implementation. Multidisciplinary governance is key to helping physicians transition from independence to collaboration. 

2. Get Agreement on Objectives and Be Honest About Differences

Conflicts arise during an EHR implementation that easily can derail the project. For instance, physicians often request electronic connections to independent labs. But this undercuts the goal of clinical integration. To avoid such distractions, the governance body needs to establish agreements on the strategy and core objectives.

Hospital culture tends to be methodical and risk-averse, while physicians are used to making quick decisions, with little need to consider the impact on others. Agreeing on the basics will help smooth out these cultural differences. A common understanding of strategy and core objectives can help:

  • physicians focus on the needs of the system and the importance of careful planning;

  • hospital administrators make faster decisions and allow stakeholders to proceed more independently;

  • both parties understand how to pick their battles by delineating what is open to debate and what is not, what is a critical concern and what is a side issue.

3. Hire Medical Practice Expertise

Hospital administrators who have not worked in a medical practice usually do not understand medical office processes and needs. This is true in every hospital department, and IT is no exception. The problem: EHR implementation teams that do not grasp ambulatory workflows often create needless disruptions.

The solution is to hire an expert who understands medical practice workflows, management processes and culture. The ideal expert is someone with direct experience working in a small practice setting — for example, a former practice manager who has been through an EHR implementation.

An implementer with medical practice expertise will understand how to interact with physicians and office staff. He or she will be able to foresee implementation problems and configure the EHR system to meet individual practice needs.

4. Form Collaborative Task Forces

Even with medical practice experts on the implementation team, hospitals need a way to learn from medical practice staff members about what will — and will not — work in their office. The solution is to create implementation task forces that include key individuals.

Nurses, practice administrators, medical records staff, billers, even receptionists all should be represented. Establish an overall task force to plan EHR configuration and processes, and break out smaller groups to tackle specific issues like template design and process metrics.

Collaborative task forces can anticipate user problems that hospital IT staff would never see coming. They also build a sense of shared ownership for the EHR system. In addition, task force members are able to support their coworkers after implementation, reducing the practice's reliance on hospital IT.

5. Build a System, Not an Assembly Line

Implementing an EHR system for a physician network will require medical practices to adopt some standard workflows and clinical protocols. While standardization is necessary, it can create problems in individual situations and for certain medical specialties. A rigid approach to workflow design will breed resentment and result in a poorly functioning system.

Here's a rule of thumb for EHR implementation decisions: Don't force any changes that won't improve care quality or bottom-line results.

Say a group of family physicians wants to use voice recognition software to create referral notes. Some hospital-led implementation teams oppose voice recognition technology on the grounds that it does not generate discrete data within the EHR system. But meaningful use regulations and quality initiatives do not require all documentation to be formatted as discrete data. Since voice recognition technology may improve quality of care and make life easier for physicians, the best decision is to allow its use in the proper place within an EHR environment.

6. Rip Off the Band-Aid®

Even with good planning and risk mitigation, an EHR implementation is expensive and resource-intensive. The issue before hospitals and physicians is this: Do you want it to be quick and expensive or slow and expensive?

Both parties must devote resources up front to ensure a prompt and efficient EHR rollout. Physicians need to set aside time to learn the system, which means temporarily cutting back their schedules. Hospitals need to provide additional support to soften the impact on physician productivity. Some hospitals provide physicians with medical scribes to assist with the transition to electronic charting, while other hospitals supply temporary nursing support to help practices maintain patient flow.

These moves add expense to an implementation project, but they are a small investment when weighed against the risks of a failed rollout.

Here again, agreement on core objectives (see Step 2) is important. Both hospital administrators and physicians must be able to understand why they are making the change if they are to maintain commitment to the implementation and make needed investments.

7. Share Accountability

While the system rollout requires a big push, the work does not end there. All stakeholders must have ongoing accountability for creating high-performance electronic health records.

The hospital, of course, is responsible for maintaining the system and providing training. Physicians are responsible for using the system well. Ultimately, successful EHR adoption and meaningful use depend on what happens at the practice level.

While physicians need to make time to learn the new system, they also need to attend training sessions (you might be surprised by how many do not). Medical practice staff should participate in planning and implementation. Practice representatives also should take part in EHR user groups — collaborative learning groups that allow staff to share best practices and solve system problems, ultimately reducing their long-term reliance on hospital support.

Hospital administrators and physicians need to work together on continuous improvement. This is where the governance structure is still important, because there needs to be a body that identifies improvement goals and enforces behavior change for the sake of the entire system.

Best Chance for Success

Each of these steps will minimize the problems that can arise during a hospital-led EHR implementation. Together they allow hospital leaders to ensure the best chance of success for an electronically connected physician network.

Topics: EHR, EMR, HIT, Employed Physicians, healthcare consulting firm, Hospital Technology, hospital consulting, Affiliated Physicians

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