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10 Emerging Characteristics of High-Performing Hospitals

Posted by Matthew Smith on Jun 8, 2015 9:01:02 AM

For decades, hospitals across the United States have operated within a challenging, rapidly changing, and fragmented healthcare system. Today, this environment is even more complex as healthcare reform and market forces transform the way healthcare is delivered and managed, shifting focus from fee-for-service to value-based care models. While healthcare providers are increasingly pressured to improve clinical quality at a lesser price, many have a long path of improvement to achieve sustainability in this post-healthcare reform era. Here are 10 emerging characteristics of high-performing hospitals in the value-based care environment.

1. Defined Strategic Vision

According to a 2014 global survey commissioned by the American Management Association and administered by the Institute for Corporate Productivity, the single largest gap between high-performing and low-performing organizations is whether organization-wide performance measures matched the overall strategy. The second largest gap between high- and low-performing organizations was due to whether organizations had clear and well thought out strategies to support the strategic plan1.

High-performing healthcare organizations have a strategic plan that sets a clear direction for the organization, and there is proper alignment between the strategies set forth and the organization’s goals, tactics, and measurable outcomes. Further, the strategic plan is hard-wired throughout the organization across all departments, engaging physicians, nurses, and staff in the process and making them accountable for achieving the organization’s overall goals.

2. Consistent Leadership

Leaders in high-performing healthcare organizations consistently demonstrate the mission, vision, and values, and ultimately drive the direction of the organization. These leaders are responsible for thinking strategically, allocating appropriate resources, building engagement, driving accountability, and achieving results – all in collaboration with very different stakeholders (physicians, nurses, staff, board members, and vendors).

Given that the healthcare industry overall faces an aging workforce, high-performing healthcare organizations have developed a pipeline of future leaders whose skills match their future needs. These organizations identify potential leaders, both clinical and non-clinical, and develop skills and competencies needed for the future. According to a survey of more than 5,000 executives conducted by The Boston Consulting Group and the World Federation of People Management Associations, high-performance companies fill 60 percent of top management roles with internal candidates, while low-performance companies fill only 13 percent internally2.

Lastly, high-performing healthcare organizations directly link leadership strategy to the organization’s overall strategic direction. Regardless of who the C-suite may be, operational execution takes place at the mid-level and supervisory levels of the organization, and involves engagement from physicians, nurses, and staff. High-performing healthcare organizations invest in their success, and actively monitor and work to strengthen their engagement and skills3.

3. Talent Management (don’t tolerate the low performers)

High-performing healthcare organizations focus on the development of their talent, managing people in the challenges of healthcare reform, strategic initiatives, and operational and performance improvement initiatives. These organizations are proactive in managing their talent and are quick to identify individuals that are not meeting performance targets, implementing necessary measures (e.g., talent replacement, mentoring, among others) to ensure that the organization’s performance remains on the projected path. According to a 2014 report published by the Project Management Institute (“PMI”), only nine percent of organizations surveyed rated themselves as excellent on successfully executing initiatives to deliver strategic results. Further, the PMI found that high-performing organizations successfully complete 89 percent of their projects, while low performers complete only 36 percent; high-performing organizations wasted nearly 12 times fewer resources than low performers4. Thus, high-performing healthcare organizations have more successful operations and waste fewer resources because they effectively align talent management to strategy.

4. Culture of Accountability

High-performing healthcare organizations are constantly looking for ways to improve the quality of care provided in order to achieve the Institute for Healthcare Improvement’s (“IHI”) Triple AimTM of: 1) improving the patient experience of care (including quality and satisfaction); 2) improving the health of populations; and 3) reducing the per capita cost of healthcare. In order to achieve these objectives, high-performing healthcare organizations have adopted and hard-wired a culture of accountability throughout the organization. A culture of accountability serves as a vehicle to reduce inappropriate utilization of healthcare resources; increase utilization of, and adherence to, clinical practice guidelines and evidence-based medicine; improve patient care outcomes; and ultimately create a continuous learning environment. As healthcare organizations seek to create a culture of accountability, it is critical that the following key factors become integral to the organization’s culture:

  • Provide consistent leadership and involve physicians
  • Focus on quality and the underlying processes required to sustain high levels of performance
  • Ensure customer service and patient satisfaction are forefront priorities across the organization
  • Regularly measure and monitor performance
  • Adopt and implement an infrastructure to support achievement of the organization’s objectives

5. Change Management and Adaptability

In this era of healthcare reform, high-performing healthcare organizations have the ability to rapidly adapt to changes in the marketplace and engage key stakeholders in the process. These changes include shifts in demographics, health status, and patient care needs; technological advancements; reimbursement changes; and transitions to emerging value-based care models. Not only are these organizations able to quickly adapt, but they have a disciplined approach to drive shifts in focus, strategy, direction, structure, and culture throughout the organization through innovation and by developing alternative approaches that maximize impact – usually through more cost-effective, higher quality of care. Further, high-performing healthcare organizations are prepared to respond to failures, and continually find new solutions, and their resilience and quick problem-solving prevents disasters.

6. Transparency

High-performing healthcare organizations drive organizational awareness and quality performance through improved communication and data sharing. These organizations provide sufficient, easy-to-access information to the right person at the right time for the right patient, facilitating evidence-based decision-making, and appropriate and timely measurement of quality and key performance indicators. Further, high-performing healthcare organizations are able to successfully align governance with the use of data and information to drive performance improvement. Comprehensive sharing of information and best practices means alignment between leadership and physicians, nurses, other clinicians and staff around strategic goals, data-driven decisions, transparent metric analysis, and timely reporting. This helps to ensure that patients receive consistent care while improving overall quality outcomes at lower costs.

7. Outcomes

The healthcare industry is becoming increasingly consumer-driven. Patients have greater decision-making power in managing their healthcare budgets, and the increased transparency of healthcare outcomes data allows patients to compare and select providers based on published reports. As competition intensifies, patient satisfaction, service quality, and efficient resource management have become the basis to measure patient, clinician, and organizational outcomes. High-performing healthcare organizations have developed a strategic quality plan that sets the direction for quality improvement by creating a strong patient focus and demonstrate continuous commitment to achieving the organization’s quality improvement goals. Further, these organizations have hard-wired evidence-based practices throughout the organization to ensure performance targets are met, and have engaged physicians, nurses, and staff in this process. This is particularly important, as shifts in payment models link reimbursement to quality outcomes. Thus, the benefits of high-performance are recognized in multiple areas:

  • Financial outcomes, through higher revenues and lower costs
  • Clinical outcomes, through higher quality of care and more efficient clinical resource utilization
  • Operational outcomes, through healthier patients at reduced costs and improved processes and workflows to manage information and enhance patient experience

8. Alignment with Physicians Through Clinical Integration

Healthcare reform initiatives are forcing all providers to reevaluate current partnership models in light of future accountability mandates. As reimbursement systems evolve, hospitals and physicians will share an increasing amount of joint accountability for the care they deliver, which will require a defined infrastructure to evaluate costs while delivering higher quality care. High-performing healthcare organizations have adopted a clinical integration strategy that allows both the hospital and its physicians to achieve these goals by jointly participating in value-based contracting models. This provides opportunities for both parties to collaborate through coordinated patient interventions, management of quality across the continuum of care, movement towards population health management, and pursuit of value-based contracting – all of which are key critical success factors in today’s age of healthcare reform.  

9. Patient Engagement

To build and maintain patient loyalty and engagement during a time when consumers can shop for the best value, healthcare organizations must not only provide quality care but also exceed patient expectations. Patient experience and emotional engagement have become critical factors to achieve improved health outcomes and lower costs, and research conducted by Gallup suggests that high levels of engagement among physicians, nurses, and staff are key to developing and maintaining these critical patient relationships. For example, engaged employees are enthusiastic and willing to go above and beyond the basic standards of performance, which makes them more likely to anticipate patients’ needs and create a positive patient experience5. High-performing healthcare organizations cultivate provider-patient relationships and apply strategies to build patient engagement, allowing patients to become more active participants in their care. These strategies include empowering employees to problem-solve down to the front-line levels, as well as deploying behavioral interviewing techniques to hire the right people for the right positions.

10. Innovation and Care Redesign

High-performing healthcare organizations adapting to transformational payment systems and payment reform have determined it is not business as usual. Many organizations cannot afford sophisticated benchmarking or best practice comparisons. A beginning strategy in care redesign for bundled payment and other payment reform initiatives includes comparisons to internal best practices in both cost and quality. Additionally, high-performing healthcare organizations have implemented systems such as Lean and Six Sigma to involve frontline staff and physicians in identifying unnecessary, non-value added testing and processes.  Competency in care redesign is a critical skill in an organization’s efforts to reduce costs, eliminate variation, and streamline transitions in care. High-performing healthcare organizations have learned how to enhance care transitions and move outside the walls of acute care hospitals and into post-acute settings to reduce readmission rates and potential complications.


  1.  American Management Association. “The Essentials of High Performance Organizations.” October 6, 2014. http://www.amanet.org/training/articles/The-Essentials-of-High-Performance-Organizations.aspx
  2. The Boston Consulting Group. “High-Performance Organizations: The Secrets of Their Success.” September 2011.
  3. The Boston Consulting Group. “High-Performance Organizations: The Secrets of Their Success.” September 2011.
  4. Project Management Institute. “The High Cost of Low Performance.” February 2014.
  5. Burger, Jeff. “Why Hospitals Must Surpass Patient Expectations.” Gallup Business Journal. May 1, 2014.

Topics: Clinical Integration, Hospitals, Patient Engagement, Strategy, Care Redesign, Hospital Pricing Transparency, Hospital Performance, Performance Improvement

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

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

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