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.
- Integrated governance – “It’s a constant work in progress.”
- Challenges of being a CIN – “We need to define a new, integrated way of working”
- Breaking down siloes to support care redesign
- Different markets, same road map
- “It’s important that we build trusting relationships.”
- Disruptive forces in pop health
- “It’s the toughest job I’ve ever had.”
If you enter into contracts that include all of the care requirements and performance pieces you need to have in place across each provider organization, you really need to define a new, integrated way of working. It is a really huge cultural shift.
Every neighborhood network that we have has a slightly different market, and they may not all agree on the trajectory of how quickly we’re moving to risk and what it might mean for them. And so it is really important that we build trusting relationships and we understand the different needs.
It’s an area where every day you’re going to say, ‘I don’t know,’ because you don’t know. The market’s really changing. The IT solutions in this space are absolutely not mature.
When you’re in the innovation and early adoption area, it’s a lot more risky, so how do you navigate that gap when you’re moving into a new payment environment?
Gamble: Let’s talk about governance. You mentioned the importance of having a solid governance program in place across the network — I’m sure that comes with its share of challenges, particularly when you’re dealing with hospitals and practices with very different sets of needs. What have you found to be the keys to getting that governance piece right?
Bonello: First, just for context, I will say that we had a bit of an advantage because we had a longstanding, mature governance structure at Rush Health, so that was good. The key was in realizing we needed to reorganize the governance structure for population health.
Two, when we did that, we needed to the integrate IT people into that population health governance structure. We do have a separate IT governance group that deals with some of the technical interoperability pieces, but in general, what we do in IT is really driven out of the population health governance structure, so I think that was crucial.
The third piece — and it’s still not perfect — is defining the roles and responsibilities between the clinically integrated network and the provider organization. We’re not the provider organization, so we don’t provide care here at Rush Health. So when we work with the members to redesign clinical delivery workflows and leverage technology, it really has to be implemented within the operational areas for every member.
I always frameworks as a way to help everyone understand. What I say is, we help guide and we help with the planning and the solutions design. I have people at Rush Health who are focused on workflow, and then I with the different Epic IT shops — they’re sort of like a development partner. We work collaboratively as a team, but we very much have the methodology to do a lot of the design and to assist in the management and monitoring to help get this rolled out and to put it in context of where we are within the value based care payer strategy and what it might mean, and relating it to our performance requirements in the contract. The build takes place in other environments, and the implementation takes place across our member organizations, and we have resources here to help with the management and monitoring of how well things are going.
Think of it as a really big continuous PDCA (plan-do-study-act) cycle across all of our different members. Nothing is siloed now. If you enter into contracts that include all of the care requirements and performance programmatic pieces you need to have in place across each provider organization, you really need to define a new, integrated way of working. It is a really huge cultural shift. We can’t do anything in a vacuum at Rush Health. It’s really driven by how well we all work together to support care redesign.
Gamble: When you’re talking about defining the roles and responsibilities of the clinically integrated network and the provider organization, I’m sure that’s not a simple process.
Bonello: It’s a constant work in progress. So everyone has to agree on the roadmap and that’s hard. Every neighborhood network that we have has a slightly different market, and they may not all agree on the trajectory of how quickly we’re moving to risk and what it might mean for them. And so it is really important that we build trusting relationships and we understand the different needs of our neighborhood networks. From an IT perspective, I’ve developed what I call partner portfolios for the different work that we do with each member neighborhood network. From an interoperability standpoint, we as a network have to agree on it, because the success of interoperability depends on the sender and receiver functionality. So that’s one time where we all have to be in lockstep with one another and agree on resources and agree that whatever we have on the Rush Health plan is also on the IT plan for every other member. I’ve worked very hard at doing that, because I need to work with the members so that Rush Health demonstrates value for what they need.
Gamble: Very interesting. It makes me think of the air traffic control analogy where all of these moving parts have to work together in a seamless way.
Bonello: Right, and everyone has to agree that we’re going to the same place. We may be taking slightly different routes, but we’re getting to the same place — and hopefully there’s no road rage.
Gamble: Exactly. And I’m sure having that foundation in place has been key in all of this.
Bonello: Definitely. If you think about the innovation technology curve — sometimes it’s just called technology adoption curve, sometimes innovation adoption curve — back in 2000 when we were implementing EHRs across the nation that technology was in the innovation/early adopter area, so there were all these studies looking at the return on investment. Now EHRs are in the early majority/late majority area where we’re optimizing and ensuring that they’re safe. It’s very important that those systems are safe for care.
But we have two disruptive forces going on right now in population health. Number one is the huge, national shift into value and risk which is driven by payers and is driving the population health strategy. Two is the disruption we’re finding with the digital landscape, and both of those are in the innovation and early adopter space. So in order for a clinically integrated network to be successful, we have to think about the people, the structures, and the processes we need to be successful in that space, knowing that a lot of our members operate in the early majority/late majority area. So it’s always really tough. It’s the toughest job I’ve ever had.
Gamble: I’m sure you knew it was going to be a challenge. Was that part of what drew you to this role?
Bonello: For me, it was about being able to have a bigger impact and footprint, because I knew that Rush and the rest of the market here was just entering into value based care or would be shortly. It was also the complexity at Rush. At Access Community Health Network, we were the largest Medicaid primary care provider, and everyone was employed, so when we put a strategy and a governance structure together, it was easier to get everyone to agree to the way we were going to do things. Access is where I really learned about population health — I learned that you had to have practice transformation and a really good care delivery model defined in order to make long-term changes.
When the opportunity rose to help create that at Rush Health, a more complex system, I thought it sounded like a great opportunity, and it was. It’s exciting. It’s really hard, but it’s very exciting, and it’s super intellectually stimulating. It’s an area where every day you’re going to say, ‘I don’t know,’ because you don’t know. The market’s really changing. The IT solutions in this space are absolutely not mature, and so you really have to realize all of the decisions you make are not going to be 100 percent something you’re going to stick with, and you might go through some failure. It’s that type of innovative, entrepreneurial type environment I find stimulating, and even more importantly, it’s being able to have a bigger impact on care.
Gamble: You just touched on something really important — a willingness to recognize that something isn’t working and it’s time to make a change. That’s not easy to do, but it seems to be a key part of the philosophy at Rush.
Bonello: It’s definitely not easy, because normally within health systems, you want to be risk-averse. When you think about the publications that came out — ‘To Err Is Human’ and ‘Crossing the Quality Chasm’ — it’s all about stability and zero defect. And when you’re in the innovation and early adoption area, it’s a lot more risky, so how do you navigate that gap when you’re moving into a new payment environment?
Gamble: Right. That’s the big question so many are facing right now. Well, I want to thank you so much for your time. This has been a really interesting discussion, and I hope we can speak again in the near future.
Bonello: That would be great. Thank you, Kate.