One of the biggest pain points for CIOs—at large health systems, community hospitals, and everywhere in between—has been positioning themselves as Accountable Care Organizations. The ultimate goal of aligning the patient, provider, and insurance carrier to provide quality care at a low cost is not an easy one, especially when factoring in Meaningful Use, ICD-10, and other top priorities. To help provide some guidance, a number of leaders—including Steven Riney, CIO of Methodist Medical Center of Illinois—collaborated with Premier to develop a multi-phased ACO roadmap. In this interview, Riney talks about what it takes to make the ACO transformation, how Meaningful Use has challenged vendors as well as healthcare organizations, and how Methodist worked with their vendor to tailor a system that accommodates the needs of different specialties.
- About Premier’s ACO Capability Roadmap
- Baseline technologies for an ACO
- From capturing to leveraging data
- ACO/MU ties
- Implementation sequencing: what to do first?
- The Premier/IBM relationship
We’ve gone all the way from just capturing some data to really being able to leverage that data and transform what we’re doing with revenue and incentive models, scenario planning, and population health performance forecasting.
If you can make a delta between where you’re projected to be for your cost and where you actually end up, there’s a shared savings possibility that you can share throughout the entire ACO—your organization, and those organizations that you partner with.
The ACO has to be so much broader than acute care-focused. What we have to be able to do is have a full EMR within our physician practices, and within the practices we partner with.
I figured out that we can’t do an ACO; we have to be involved in multiple ACOs, some of which we’ll drive and some of which we’ll be part of, and that dynamic is going to be challenging as we try and move through this whole transformation.
It allows us to be able to give that patient a better outcome and put things in front of the patient that make sense, not only for the next three months, but for the next five years and the next ten years of that patient’s life; to make sure we’re doing the right things for the right reasons over the long haul.
Guerra: Good morning, Steven. Thanks for being with me to talk about both your work with Premier and your work at Methodist Medical Center.
Riney: Good morning.
Guerra: Let’s start with Premier. About a month ago, Premier released some information about an ACO Capability Roadmap. Why don’t you tell me first about your involvement with Premier, and then about this roadmap—how it came about and what its objectives are.
Riney: Right around April of last year, we got together as a Premier implementation collaboration group. We have some hospitals that are really advanced, some hospitals that are sort of in the middle of the pack, and some hospitals that want to do the ACO but are behind the pack. So you’ve got the full continuum there. AtlantiCare is there, along with Banner Health, Fairview, Geisinger, Hoag Presbyterian in Albuquerque, SSM—a lot of really good people. And we pulled this group together more than a year ago now, and we started asking what we need to do to take advantage of health reform and the ACO.
The focus of the ACO is basically cost, quality, and patient satisfaction, and the folks in this group—I think there are 32 of us in total—are at the forefront of trying to make some changes in the industry to really focus on what has been done and what we need to have done through legislation and rule-making. It’s been a very interesting time period since then. There are some great people in that group.
One of the things that we did a couple months ago is we put together an HIT Capability and Maturity Model for an ACO. Because we haven’t had ACOs, we didn’t know what we would need for a level one transactional ACO just to get things up and off the ground, and then run that through interaction, integration, collaboration, and then finally where we all want to get, which is the transformation. That whole framework has been something that the population health group, which is basically the IT folks within the collaborative, had been working a lot on over the past eight months or so.
Guerra: Give me an example of a hospital executive looking at this ACO stuff. What is one scenario in which this handbook can really assist them in terms of moving forward?
Riney: I can do that. From a level one perspective, you’re going to have to have a few things. You’re going to have to have some provider-centric quality reporting. You’re going to have to be able to do physician profiling, some resource utilization, productivity—you have to have an HER to be able to manage the services. You’re going to need a patient portal, registration, and an enterprise master patient index. That’s sort of level one, if you will. That’s where you start; you’re going to need those things as entry to the game. Once you get through the interaction, integration, collaboration and transformation, level five is real-time feedback loops on outcomes analytics between providers and patients.
So we’ve gone all the way from just capturing some data to really being able to leverage that data and transform what we’re doing with revenue and incentive models, scenario planning, and population health performance forecasting. From a population transaction system—personalized self management and health improvement programs, and then access to health and wellness information at the finger tips when they need it, pushed out to them in a manner that’s easily digestible. The idea is that as we move through this transformation process, we want to get to the place where we can really facilitate our customers, our clients to be able to take advantage of that, and so we can help them deliver care at higher quality and lower cost and to be able to have the patient satisfaction; to have them know that we’re there to take care of them well into the future.
Guerra: The regulations came out recently on ACOs with some detail from the government. I believe that came out after your handbook was finished, and the one major thing that I saw in there was a requirement that at least 50 percent of an ACO’s primary care physicians must be Meaningful Users by the start of the second performance year. Did anything that was in there change what you’ve done or reinforce what you’ve done, and what are your thoughts around that 50 percent requirement?
Riney: Yeah, I don’t think that’s going to be a big impediment, specifically for Methodist, and I can’t imagine that it’s going to be an issue for the other quality organizations in this collaborative either. With Meaningful Use and some of the things that are happening there, that’s another conversation we’ll probably have later, but I don’t see that as being a big issue.
I do see some things that might be concerning. One of the things we’ve looked at is you can save a half million dollars in total cost, and the important piece is where you are now and what you are projected to be a year from now. And then if you can save some element of that; if you can make a delta between where you’re projected to be for your cost and where you actually end up, there’s a shared savings possibility that you can share throughout the entire ACO—your organization, and those organizations that you partner with. So that’s the target, and the challenge that we see in the current regulations is that you can save a half million dollars and get back $20,000, and that type of economics just won’t work. And that’s the Medicare stuff that I understand is coming out. That economics won’t work; there has to be a real savings there, and I think there’s real possibility, but I don’t think that possibility is manifested in the rulemaking that’s been taking place.
Now just because it’s Medicare, that doesn’t mean there aren’t a lot of other possibilities for an affective ACO with a large employer or with a large carrier to be able to negotiate the right kind of shared savings incentives that really align us all on the same thing. We’re all aligned at that point in time, and that’s what an ACO will do. It will align the carrier, the patient, and the providers to provide the best care and lowest cost and highest quality.
Guerra: We’ll definitely get a little more into Meaningful Use and talk more about your work at your organization, but let’s stick with the Premier Handbook for a little bit. One of the things stated by your organization was that this was going to help people deal with sequencing in terms of the technology they bring in their organization. So my question is obviously sequencing is extremely important, but there really isn’t a one size fits all. I’ve spoken with a number of CIOs, some of them feel passionately about doing sequencing one way in terms of e-prescribing, bedside barcode medication, CPOE and physician documentation—they each have their own preference and a lot of that is based on their organizations. Meaningful Use has taken that out of their hands, and told them what they have to do and in what order. What are your thoughts around sequencing in terms of implementing technologies and how you’ve address that in your handbook?
Riney: Well the things that you just mentioned—those are really acute care-focused, and the ACO has to be so much broader than acute care-focused. What we have to be able to do is have a full EMR within our physician practices, and within the practices we partner with. We have to have electronic connectivity with our home health system and with other home health systems with whom we might contract. So it’s not a laundry list as much as it is capabilities. We can go and get CPOE up; in fact, we’ve had it up for several years now. So that’s not the focus, and I think that’s one of the challenges of Meaningful Use. We’ve got the opportunity with ACO, but we have to do some of these Meaningful Use things also, and to be able to do both of those at the same time across an effective transformation model for an ACO, will prove to be a challenge.
Guerra: An ACO is essentially an integrated delivery network, and there are a lot of those out there where you have all the components, especially Kaiser, Geisinger, and these organizations that have the payer component. But even for the ones that are missing the payer component, there are a lot of hospitals integrated with their own practices. If your organization is traditional community hospital that is pretty much a standalone, you need cooperation and you need to have conversations and you need to encourage independent physician practices to get EMRs and integrate with them. There is a lot of work here that you don’t have total control over where you need cooperation, does that make sense?
Riney: It absolutely makes sense, and the only thing I would say is we are an integrated delivery system, but I would add the world ‘virtual’ in front of your description of the ACO. It doesn’t have to be wholly owned; in fact, there will be motivation for some people that own a piece of something that they can’t provide the care as effectively as someone else who can provide it. So there will be motivation for them not even to use their own owned resource at times, and to be able to partner with players within the community to deliver the best outcomes they can to really expand that savings curve and increase that quality curve; to really make a big statement and a big impact on the population health of the area. So the payer piece is an element. We don’t own a payer—we used to, but we don’t any longer. If we have that, a lot of this could be a lot simpler.
And one of things that surprised me as we were getting closer to doing an ACO, and this was over a year ago when I was sort of trying to understand what this meant, and then ultimately I figured out that we can’t do an ACO; we have to be involved in multiple ACOs, some of which we’ll drive and some of which we’ll be part of, and that dynamic is going to be challenging as we try and move through this whole transformation—the transaction, interaction, integration, collaboration and then transformation continuum.
Guerra: I recently wrote a column that talked about leading and following, and in order for Premier to lead, you have to follow what the government is doing and what other organizations are putting out. You put out a handbook to try and help guide people, but to create a handbook you have to see what’s going on and follow and do your best guess to show what the future is going to be when we don’t know a lot of things; how the details are going to be worked out. Tell me about that in terms of your work at Premier—how you go about ascertaining everything you need to in order to provide a handbook.
Riney: I think one of the best things about the Premier Collaborative is that we are in a position where we are taking a leadership prospective. And you’re right, you have to understand that you have to do some following, but then you understand what’s being required or what’s being requested. You have to identify the things that are not there today and need to be there, and then there is a whole group within Premier that’s on the Hill making these things happen on a day to day basis. What was nice is last summer we got together as a collaborative, and during that period of time, we actually had my CEO, two other CEOs, and some folks from Premier actually meet with a few representatives and a Senator. The interesting thing about that is that it was the first time in years that Republicans and Democrats have been on the same stage talking about healthcare reform.
And that’s the kind of leadership that I think Premier has allowed us to be in a position to deliver. It’s not done yet—there are a lot of things that need to happen. We still can’t do an ACO effectively; they do this virtual partnership because some things that we would share with the virtual partner could be considered anti-trust issues, and the FTC would need to be involved. So we’ve tried to get folks from the various groups within the government to talk together and they’re doing that, but that’s not done yet.
Guerra: One of the other interesting things in what you’re doing, and I read this in your release, is that ‘IBM and Premier are developing an industry-first technology platform that will support this model to improve population health. It will allow doctors, hospitals and other health providers to work together and enhance patient safety.’ This is interesting—is Premier essentially partnering with IBM on some sort of platform to become a vendor in some way?
Riney: Well one of the things that Premier has done for years is really take hospital data and put it together in such a way that we can maximize our purchasing efforts. That’s their history 20 years ago, and they’ve gone into a lot of the quality indicators. We do a lot of quality measurement and pushing the quality curve and safety curve—those kinds of things using Premier, and we do a lot of it. So there’s a lot of data that’s being captured in each of those initiative that we’re part of and we’re measuring. So it makes some sense to take a step back and say, ‘Okay we’ve done this initiative, we done that initiative and maybe three more or 10 more initiatives,’ and we’re capturing a piece of data for each of those things. There are several pieces of data for each of those things. I think what Premier has done is to say that we need to have something that’s a little bit broader to be able to have an analytics platform as opposed to just capturing data and reporting data; we need something that we can get multiple uses out of.
Premier has partnered with IBM to begin the design, and it’s not a small task, to move Premier from this silo mentality of ‘Here’s what we do for purchasing; here’s what we do for quality; here’s what we do for safety’—to something that’s more uniform and would include the ACO at that point in time also. So there would be an analytics component.
Now we’re doing it in such a way that the data, when it’s all done, will be available in a couple different ways. It will be available on the Premier site where facilities can go in and get that data, and it will be available on an ad server within your hospital and be replicated back and forth. So it’s something that’s far from complete. It’s done at this point in time, but it’s something that Premier believes will be very beneficial to the Premier owners, the Premier members, and the Premier ACO Collaborative.
Guerra: I’ll just read your quote from the release: ‘The idea is to provide evidence-based clinical support at point-of-care delivery, helping doctors, clinicians and others make faster, better decisions in how to care for individual patients.’ That sounds to me like the basic clinical decision support based on evidence-based medicine that you’re supposed to get with any main acute EMR System. How is it different?
Riney: It’s different in the people who are doing it, and it’s different in the motivation that it’s being done within. With traditional healthcare, it’s all about the transaction—I do one more of these, I get one more dollar; I do two more of these, I get two more dollars.
Riney: And this isn’t how we operate, but the motivation of traditional organizations is the more transactions, the more outcomes in terms of financial, which is not necessarily aligned to the more outcome in terms of financial and the more outcome in terms of quality. Nor is it necessarily aligned to the more outcomes in terms of patient satisfaction.
So the difference here is we want to do the right thing for the right reason at the right time for that patient—not only from a reactive prospective but from a proactive prospective. And you’re right, a lot of hospitals have set these kinds of thing up already. But the motivation to be able to share in that savings—that delta between the projected and the actual realized cost is a good motivator. And it allows us to be able to give that patient a better outcome and put things in front of the patient that make sense, not only for the next three months, but for the next five years and the next ten years of that patient’s life; to make sure we’re doing the right things for the right reasons over the long haul.
Guerra: Were you involved with selecting IBM? I’m wondering how Premier picked IBM as a partner and what the process was like.
Riney: I was not involved in that. The folks at Premier had been looking at trying to rationalize what they’ve been doing in this arena for a while, and they had some conversations with IBM when we got to the ACO and that started percolating. IBM has a lot of payer types of data and payer history that they can bring into the table, and that sort of made it a natural fit. But that was mostly a Premier process.