Typically, physician face time during a patient's office visit is measured in minutes. However, accountable care is changing that scenario at Orlando (Fla.) Health, a large integrated delivery system with eight hospitals. At some of its outpatient practices, it's implemented group medical visits, at which 10 to 12 patients with similar conditions get 90-minute discussions with a physician, nurses and other care specialists.

At these extended visits, patient problems and questions are approached from a variety of angles, all intended to help patients stay well and keep them out of expensive care settings. "We're setting the patients up for success," says Tawnya Adkisson, director of care coordination for Orlando Health.

As more risk-based reimbursement models emerge, providers are radically changing patient interactions, and they're looking for support from IT to do it. Value-based reimbursement approaches will put a premium on keeping patients as healthy as possible, identifying conditions before they become serious and managing chronic conditions. That will require more emphasis on predictive capabilities, analytics, and the free exchange of information between information systems and all providers treating patients.

And all that will necessitate a quantum leap for current information systems, which are primarily transactional: They reflect past priorities of healthcare organizations-gathering care delivery information, focusing on charge capture and maximizing reimbursement. Future IT systems will need to capture patient information from across the continuum of care, enable organizations to manage care, facilitate cost-effective transitions of care, analyze population health needs and engage patients as consumers.

"This is a tectonic shift in (IT) architectural needs," says Greg Walton, CIO at El Camino Hospital in Mountain View, Calif.

Providers face big capacity challenges to adjust to the new reimbursement environment. Resources have been stretched in recent years just trying to keep pace with implementation of electronic health records to gain incentives from the federal EHR incentive program. While EHRs are necessary to support new reimbursement models, it's only a start. Interoperability is just beginning to be addressed; additional information systems will have to be layered on top of them, and a new breed of informaticists will be needed to slice and dice data to produce actionable findings.

IT systems will need to support new approaches for delivering care that maximize savings and proactively monitor covered patients so patients' care needs are anticipated. Overall, the goals for future IT systems will be very different from what they are now. Organizations such as Orlando Health, Mosaic Life Care, El Camino Hospital and JFK Health System are now wrestling with how to retool IT to successfully manage value-based payment approaches.

Incentives reversed

Orlando Health is revamping these physician encounters, and making many other changes in its approaches to caring for patients, in response to the new incentives of value-based payments it receives through accountable care organization (ACO) arrangements. These contracts encourage healthcare organizations to improve patient care and save money on care delivery; providers that reduce expenditures share in the savings they achieve.

In general, organizations haven't prepared themselves to take on the risk inherent in value-based contracts, says Linda Lockwood, advisory services solution director for CTG Health Solutions, a Buffalo, N.Y.-based consultancy. In these contracts, risk can vary, from sharing in savings achieved over the amount spent on care the previous year, to being at full risk for the care of a patient population, receiving set amounts from a payer over the course of a year.

"If they don't have an integrated system, their care is given in silos," she says. Information systems have reinforced this lack of integration; as integrated delivery systems have been cobbled together piecemeal, inpatient and outpatient systems don't easily exchange information. "All these folks were on different systems, and they didn't talk to each other. They weren't coordinating care across the continuum."

As value-based contracts become more prevalent, healthcare organizations will need a range of IT tools to succeed, says Bill Spooner, who retired last year as CIO at Sharp HealthCare, San Diego, and is now an independent healthcare IT advisor based in Tennessee.

Essential IT capabilities will include:

* a full-featured electronic health record system;

* a robust database that can be used to hold information that can be used to identify care improvements;

* analytics capabilities;

* health information exchange capabilities;

* a patient portal.

* an application to support care management by tracking everything that's happening with the patient and facilitating handoffs between providers; and

* a revenue cycle solution, which because of the complexity of ACO arrangements will need to be more robust than today's versions.

"Of those, the most critical element is analytics and business intelligence," Spooner says. "Organizations will need to do more analyses, and these will become more sophisticated. The challenge for providers is that they are new at this game; insurers have been doing it for years. Providers need to catch up, and in a hurry."

There's a premium on speed because current value-based reimbursement programs are already complex and a challenge for providers. For example, under the ACO program currently offered by Medicare, patients who are attributed to an organization can get care from any provider they desire, yet the organization contracting with Medicare is responsible for the expense. "It makes it a lot more challenging to be responsible for improving patient health or improving the financial outlays," Spooner says. Future contracts will likely be even more complex and require more actuarial capability.

Not just an IT problem

While better use of IT solutions can help organizations navigate ACO risks, other challenges require a radical redesign of approaches to population care, Lockwood says.

"You have to identify populations that are at risk, engage those patients, coordinate care and make better care transitions, and you have to have data on the back end to understand where you need to improve performance," she says. "And everyone has to be working off one problem list, one medication list, and that information has to move back and forth, so everyone has visibility into that patient."

Orlando Health had been acquiring physician practices for several years, and in fall 2012 implemented a population health management application from Phytel, a Dallas-based software vendor. "By having a population health management system, it allows us to look at patients who are sick and don't know it," Adkisson says. By identifying patients at risk for serious illness and intervening with treatment before medical issues became complicated and difficult to treat, "We improved the quality of our care and reduced costs, and fewer patients went to the emergency room."

Orlando Health entered two ACO contracts initially, with the CMS Medicare Shared Savings Program (MSSP) and with Cigna. By using monthly analysis, Orlando Health cut some costs and knew it was achieving savings on the MSSP, achieving ovrall savings of $3 million and earning shared savings of $1.5 million. Subsequently, it entered two more ACO contracts.

The Phytel system interfaces with the various inpatient and outpatient EHR systems in use at Orlando Health, ranging from the Allscripts Touchworks in ambulatory practices to the Allscripts Sunrise inpatient EHR at its hospitals. Standard analytics tools are used to mine the data.

Layering new technology on top of existing EHRs, and incorporating lab and pharmacy data as well, enables better patient communication, makes physicians more efficient and gives care managers the information they need to effectively manage care, in a way they never could with clinical systems that did a good job of collecting data, but didn't provide integration and analysis capabilities.

The new incentives have enabled the system to change the type of care delivered in outpatient clinics, such as the group medical visits. Those meetings incorporate support staff, such as dieticians, diet educators, behavioral health specialists and social workers. Orlando Health does not limit this type of outreach to patients involved in population health contracts, Adkisson notes.

Being able to manage care is important in these contracts, and healthcare organizations need systems that enable them to do so proactively, she adds. "The solution has to be accessible at the clinician level. You're not just looking at historic trends by an administrator; you have to be thinking about how we can make proactive changes, drilling down to the individual patient."

Willingness to take risks

Mosaic Life Care, St. Joseph, Mo., is also performing well in its ACO activities, says Brennan Lehman, CIO of the system. Operating a 352-bed hospital and employing 170 physicians, Mosaic Life has entered into four at-risk contracts, and sees an increasing number of ACO contracts in its future.

"Nearly half of patient revenues are in risk-based models," Lehman says. "Everything we have in the Kansas City area is performance-based risk. We're going to be seeing more of these risk-sharing models. We see ACOs as an initial step into full capitation."

Lehman identifies care management and technology as key components of Mosaic's ACO strategy, enabling coordination of patient care across the continuum. Mosaic leverages Cerner for its EHR platform, and has self-developed applications to support a variety of reimbursement approaches, including value-based programs, he says.

"The standard EHR systems of today are glorified billing systems focused on episodic care," he says. "In the future I see a need for not only new data mining systems but new roles within the revenue cycle space. The successful system in a capitation world will provide built-in metrics of utilization, cost, quality and satisfaction, with the capability to report to national registries.

"Within our electronic medical record, we've either developed or pushed the vendor to implement workflows," Lehman adds, citing an example within clinical decision support. If a patient condition sets off an alert, he says, the provider can take action-order medications, reassign the patient or review the record-within the alert window, without having to go to another screen.

"We can't have our clinicians jumping into multiple clinical systems when decisions are going to be made," he explains. "We've incorporated registries that are built in for workflow management. That enables the care manager and other care providers to be working from the same playbook."

Mosaic also leans on the use of the health information exchange to get a holistic view of the patient. Because ACO contracts enable patients to seek care at any provider, Mosaic gathers claims data, in addition to clinical and financial information. "The claims data that's coming through will help us identify any blind spots in the management of a patient," Lehman says.

After patients are treated, they are typically transferred as quickly as possible to the least expensive care setting that can safely handle them as they recover; they can go home and receive home care, or can go to a long-term care facility if they need more support with activities of daily living. As a result, in a cost-conscious, value-based care world, hand-offs to non-acute settings will become increasingly prevalent. "ACOs have enabled new technologies that have been here forever," Lehman says. "Telemedicine has never had a reimbursement mechanism behind it, but with the ACO model, we can apply whatever technology can help us. It's a no-brainer."

A costly transition

The shift to ACOs signals a new role for hospitals, says Greg Walton, CIO at El Camino Hospital, Mountain View, Calif. Walton sees hospitals as becoming "procedural factories," while the bulk of the care will take place in non-acute settings, including patients' homes.

However, the bulk of investment in information technology has occurred in hospitals, and extending the reach of technology to long-term care facilities, home care agencies and patient homes will be expensive, he says. "They don't have the technology and they don't have the IT expertise," Walton contends. "It will cost a lot of money to move care, more and more, into the home or lower-cost settings."

El Camino has done innovative work in reducing patient readmissions, using predictive analysis to identify patients at high risk of readmission, and using videoconferencing between the hospital and affiliated skilled nursing facilities. However, the organization is only beginning its ACO journey-it's entered agreements to improve population health around three diagnostic-related groups of illness.

El Camino is moving away from a strategy where it used systems from various HIT vendors and will be implementing a comprehensive medical record system from Epic Systems, Verona, Wis., reducing the number of applications from the 31 different vendors it now uses. "We're also expecting to get very close to paperless, as almost all our workflows are redesigned and we add more interfaces to medical devices," Walton says.

"Additionally, more than 50 percent of the population in our service area has an Epic record in a nearby organization," Walton says. "Data exchange is key to population health, and we'll get an immediate improvement over our current state with the Epic installation."

El Camino will take baby steps into ACO arrangements, and will increase IT support as it transitions to the Epic system. "The initial IT changes for population health are small," Walton says. "As we roll out Epic, we expect to depend more on their solutions, along with our existing data warehouse. It's possible we'll add some other capabilities, but the program is set up to be iterative and start slowly. In the short term, we are writing some software to connect participating skilled nursing facilities. We think of these as bridge solutions until we know more and the software requirements firm up."

The extent of the change is not lost on Walton, an industry veteran. "My entire career, I've been building charts around single facilities, such as the hospital or physician offices," he says. "All of that is old news now; now, in places where you can't have a relationship under one corporate banner, you have to figure out how to share data, share in the risk and share in the reward. You, as the ACO owner, are faced with getting the information you need from different systems."

IT tools needed for ACOs

"It's a classic interoperability challenge," says Indranil "Neal" Ganguly, vice president and CIO at JFK Health System, Edison, N.J., which has two ACO contracts in place. The system is wrestling with the best way to get patient information from physician offices and other settings into one data repository.

One of the ACOs in which JFK is participating is through the Medicare Shared Savings Program and another through a Medicare Advantage program with the Blues program in its area. JFK started with the MSSP in January 2014, and worked through last year to set a baseline for costs.

"A lot of work the first year was getting comfortable with the data and learning how to manipulate the data," Ganguly says. "Then we looked at workflow capabilities around alerting, understanding when patients present in various venues of care, and notifying the appropriate care coordination resource. We're working with the regional health information exchange, because we may have patients in our panel that may seek services in nearby hospitals; we can't manage them fully without an HIE."

JFK is preparing to do a major clinical and financial system overhaul, Ganguly says. "Our plan is to put in a strong infrastructure, focus on a patient portal and mobile tools, and then look for ways to tie that ecosystem together. We're seeing a huge change in the care delivery paradigm," Ganguly notes. "More is moving out of the physician office and hospitals to care extenders, like walk-in clinics. There will be more in-home capabilities that we'll need to tie into our IT systems."

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