For the past few years, Rush Health has been putting the pieces in place to shift from a financially focused model to one that’s driven by clinical outcomes — a transition that has had its share of challenges. It’s a world Julie Bonello knows well, albeit on a smaller scale. For six years, she held the CIO role at Access Community Health, one of the nation’s largest federally qualified health centers, where she was able to build a strong foundation for population health and learned firsthand about the “practice transformation and care delivery model” needed to make long-term changes. Although the experience at Rush — a clinically integrated network that presents more complexity than her previous organization — hasn’t been without its share of obstacles, it’s a move she has never regretted.
In this interview, Bonello talks about the pillars of a successful CIN, why a dose of humility is needed when transitioning to value-based care, the disruptive forces in population health, how she and her team have created “a new, integrated way of working,” and the biggest obstacles when it comes to driving change.
- About Rush Health (4 hospitals & 1,500 providers)
- The shift from being “financially focused to clinically driven”
- Pillars of a successful CIN
- “You need to change clinical governance across the entire network.”
- 3-pronged strategy to create a framework
- Leveraging EHRs to support the new care delivery design
- Pop health: “You have to be humble.”
- The “big technical lift” of setting up an HIE
Practice transformation has to occur along a defined care model so that you leverage technology while you’re redesigning care across a continuum. Unless you do that, you won’t really meet your performance requirements in the contract; but more importantly, you’re not going to improve care and be more efficient.
If we don’t set up our EHRs in a way that our providers and our care team can support care across a continuum and document correctly, we can’t go on to the next major foundational component, which is interoperability.
We need to extend our entire data warehouse now to support the additional data that we’re getting. That is another very huge foundation of what we do, because we try to take the data we get, make it intelligent, and then get it right back into the record.
It’s really hard to move quickly. I tell everyone here, ‘listen, I need a two- to three-year road map on everything so I can anticipate where we might be going if we haven’t defined it already.’
Gamble: Hi Julie, thank you for taking some time to speak with healthsystemCIO.com. Can you start by providing a high-level overview of Rush Health?
Bonello: Sure. We have a unique structure. Rush Health is a clinically integrated network that includes four hospitals: Rush University Medical Center, Rush Oak Park, Rush Copley, and Riverside Medical Center, and supports 1,500 providers with a combination of employee providers and private providers. Rush Health began many years ago as a PHO. They have always negotiated all the commercial contracts and negotiated and developed the payer strategy historically. They became a clinically integrated network in 2010 in anticipation of migrating the fee-for-service contract environment to one of value moving to risk. What makes us unique is that because of their longstanding centralized contract negotiation management and monitoring across the network, Rush Health has always had provider financial feeds for our membership, and has also done self-reporting on performance to support pay-for-performance pieces with our fee-for-service contracts.
About three years ago we began our movement into the value-based side with our first ACO, and now we’re also taking responsibility for the government transition into those programs. When you do that, you switch from being financially focused to being driven clinically, because your contracts now include many requirements for care, quality, efficiency, and cost, and so there’s a lot that you need to build and put in place across your membership to do that. So Rush Health is really moving the entire network forward into value and risk.
Gamble: Was that one of the things that appealed to you when you came to the organization?
Bonello: Absolutely. I had some background in this at Access Community Health, but being able to do it here at Rush Health where there was a greater complexity was very appealing to me. Also, when I was at Access we had done it for the Medicaid managed care population and so in moving to Rush Health, I was able to help them move into value-based care across commercial and government populations.
Gamble: In terms of the overall strategy for being a clinically integrated network, what are the pillars that need to be in place?
Bonello: One of my first priorities when I came on board was to put together a population health IT strategy, and concurrent to doing that, I needed to work closely with the clinical arm. What’s really key, and what I learned at Access, was practice transformation has to occur along a defined care model so that you leverage technology while you’re redesigning care across a continuum. Unless you do that, you won’t really meet your performance requirements in the contract; but more importantly, you’re not actually going to improve care and be more efficient.
So there are some foundational things you need to do. You need to change the clinical governance across the entire network so it’s not just about one health system — it’s about using our governance structure where all of our members participate.
We developed a population health governance committee that reports directly to the board. It has two very active sub-committees: one focused on care and one focused on quality. And that was really important to do, because all of our different workflows supporting our care model need integrated work groups consisting of all of our members supporting in through one of those sub-committees. And so, rather than form a new work group for every major big initiative for redesigning care, you already have that working structure identified. So that was really important.
The second piece that was really important was working with the chief medical officer and the clinical team at Rush Health, along with our members, to define a care model framework, the components of that framework, and metrics to support that — and integrating all the IT resources as we were planning and designing — so as we began the journey, we could do it along a very structured framework.
That’s a foundational piece. The way I describe our strategy is it’s three-pronged. The first is really leveraging our electronic health records to support the new care delivery design. And in doing that, looking at how we design a centralized care management system that works across the network, and also supports the technology investments that we’ve already leveraged. That’s been a really big piece of what we do.
If we don’t set up our EHRs in a way that our providers and our care team can support care across a continuum and document correctly, we can’t go on to the next major foundational component, which is interoperability. We need correct data to share across our continuum, across our members, across our affiliate members, with the payers, and most importantly, with our patients, so it’s really a lot of work going into the interoperability space. We have a big Epic footprint — probably about 80 percent with two different instances, but we have a lot of other certified EHRs. Each member that comes on board at Rush Health has to support an interoperability set of requirements in order to be a member, and one is to have a certified EHR that can support a lot of pieces — not only for interoperability, but for sharing performance data as well.
Gamble: And so even if they’re on Epic or one of the other certified EHRs being used at Rush, I’m sure the interoperability piece is still pretty complex.
Bonello: Yes, and the interoperability piece is huge in sharing both real-time and historic financial and performance data. Sometimes the performance data isn’t real time — we capture it on a monthly basis, so the next piece really is that whole model to support the data management layer where analytics can use the data we get from our complete provider environment. We get clinical, financial, and performance data, but we also get all of the payer data for every single value-based contract. That payer data includes eligibility claims, daily event files, and performance information, and we’re trying to get more pharmacy data as well.
But we need to extend our entire data warehouse now to support the additional data that we’re getting. That is another very huge foundation of what we do, because we try to take the data we get, make it intelligent, and then get it right back into the record. We have Epic registries built for our value-based care contracts. The eligibility lists that we get for the different plans are uploaded into the registries every month so that the practices and the care management teams can work within the record. But we can also let them know when we have high ED utilization, when we have a patient with high risk factors, etc. So we’re trying to use the interoperability environment that we have along with our data management environment intelligently to get alerts and action within the record.
Gamble: There really are so many pieces that need to be in place. When you talked about making sure the practices are using a certified EHR that can support the right pieces, is that something where you had to go back in and retrofit, or did you make it so that practices have to be on them going forward?
Bonello: Rush Health has been at this a while, so there have been a lot of learnings. That’s the thing about pop health, right? You have to be humble. There’s no way you’re going to know everything, plus the market changes so dramatically. In 2010, we heard that everyone has to be on Epic, and that didn’t work. And then they said, ‘okay, we’ve endorsed three different EHRs and we’ve negotiated a good deal for you to license one of these three, and that didn’t work either, partially because of the vendor’s inability to actually support our data request requirements. So then our next duration was really looking at the national interoperability roadmap. We very much monitored the development of the roadmap and put our new approach together to align with where we were going nationally, so we then said, ‘you have to have a certified EHR that is aligned with a lot of the national interoperability standards.’
We also publish a new set of clinical integration program requirements every year that are driven by our contracts. We then map those requirements to data requirements that we need and EHR requirements that need to be imbedded, and we work with our practices. It changes every year and some of the EHRs are progressively less able to support the new requirements for value based care, so it is a give and take. We try to do whatever we can do to support those members that have certified systems that are having increasingly more challenges with some of the data requests and the requirements, to support care across the continuum and sharing data. We’re finding really big obstacles in sharing data.
Gamble: From what we’re hearing, Rush certainly isn’t alone in that regard.
Bonello: Right. We implemented a health information exchange — enabling that ability to share information is a big technical lift initially, but it soon very much moves to one of clinical workflows and care, and whether the different EHR vendors really support interoperability standards in a way where we can actually exchange data for care management and follow-up.
Gamble: What do you feel is the biggest obstacle there?
Bonello: I think it’s really hard for the ambulatory EHR market right now to keep up with all of the changes going on nationally. We moved from Meaningful Use and PQRS now to MIPS, that was a huge lift. They were just getting used to Meaningful Use — and I wouldn’t even say they were good there. When we changed to quality metrics that were the eCQM’s, that was a big lift for all the ambulatories under us. It’s really hard to move quickly. I tell everyone here, ‘listen, I need a two- to three-year road map on everything so I can anticipate where we might be going if we haven’t defined it already.’ I think it’s even more magnified when you take a look at where the ambulatory EHR vendors need to be, because they need to turn things around in a year.