Putting Healthcare Back TogetherTHE DEBATE OVER ACOs

I ssue 5 FALL 201 1

The health IT journal for the Integration Generation

HEALTH STANDARDS Integrating a HealthcareEnterprise

5 QUESTIONS Joe Moore, Radiology Consultants of Iowa

INSIGHTS North Kansas City Hospital

IN THIS ISSUE

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Are ACOs Just 21st Century HMOs?

Supporters argue that the introduction of ACOs will bring long-overdue change to patient care, shifting the focus back to the quality of care the patient receives. Health care provid-ers will be encouraged to coordinate care throughout the ACO

to the benef it of the patient’s health, other-wise they won’t qualify for certain rewards.

The many detractors of ACOs believe they are a utopia n big-govern-ment dream destined to

fail. Many argue that ACOs are simply the 21st Century version of HMOs – which were almost universally disliked by patients

– that will produce lower-quality care with fewer choices and higher prices.

In the 1990s, HMOs, or health maintenance organizations, were common health insurance plans that restricted patients

to receive ca re from designated in-network physicians and refused to pay for procedures they deemed unneces-sary. HMOs still exist today, but aren’t nearly

as common; however, the near universal dislike of HMOs led to insurance plans easing the restrictions they place on patients in regards to treatment and choice of physician.

There are, however, key differences between the proposed ACO model of care and the care patients received from HMOs in the 1990s. The main difference is in the accountability of care – in an ACO, health care providers, not an insurance company, are responsible for quality of care. The ACO caregiver will have the

If you are in or around health care, it ’s impossible to avoid the ongoing debate over the changes that Accountable Care Organizations (ACOs) will bring to the industry. Much like the political rancor over

the Patient Protection and Affordable Care Act of 2010 that first mentioned ACOs, the new model of care has passionate support-ers and detractors within the health care industry.

An ACO is a network of hea lth care provid-ers and hospitals that s h a r e r e s p on s ibi l it y for prov iding ca re to patients. According to the Centers for Medicare and Medicaid Services, an ACO “agrees to be accountable for the quality, cost and over-all care of Medicare beneficiaries who are enrolled in the tradi-tional fee-for-service program who are assigned to it.”

The rationale behind this new model of care is that the cur-rent delivery of health care in the United States is fragmented. It’s not unusual for a patient to visit different hospitals, doctors and other health care orga-nizations for the same medical condition, with ver y little or no com-munication between the caregivers. As a result, there often are too many expensive tests and diagnostic procedures performed, repeated procedures and a lack of follow-up with the patient.

The government is encouraging health organizations to participate in the ACO model of care by financially rewarding caregivers for meeting certain quality of care benchmarks that include fewer repeat visits or readmissions and patient adher-ence to standard, preventative care visits, such as an annual physical or a mammogram.

Putting Healthcare Back TogetherTHE DEBATE OVER ACOs

It’s not unusual for a patient to visit different hospitals, doctors and other health care organizations for the same medical condition , with very little or no communication between the caregivers.

Supporters argue that the introduction of ACOs will bring long-overdue change to

patient care, shifting the focus back to the quality of care the patient receives.

by Chad Johnson, Corepoint Health

Join the conversation on Twitter

Tweet Chat for Health IT, every Monday, 8:00 PM CT. Use #HITsm and participate.

flexibility to contract with other affiliated ACO caregivers or organizations without the reliance on an insurance represen-tative who may make care decisions that are not in the patient’s best interest.

Another key difference is that patients will not initially real-ize they are receiving care in an ACO. HMOs are insurance plans, so patients were acutely aware of their existence, from the lim-ited choice of physicians they were given to the insurance cards they were required to present for payment. Patients in an ACO can choose the physician of their choice, and that physician will refer patients to other caregivers within the large network of affiliated ACO organizations. Patients may only become aware of the ACO after care is complete and the ACO asks the patient’s permission to allow Medicare to share their claims data with the ACO for shared savings determination.

The goal of ACOs is to pay providers in a way that encourages them to work together, to pay providers in a way that does not encourage demand for unwarranted care, and to create an orga-nization that is rewarded for providing high quality care.

The proposed ACO model is still being refined and likely will have its fair share of problems. However, that’s not stop-ping health care organizations who are taking huge steps, at significant financial cost, to qualify to become an ACO – such as implementing electronic health records and creating seam-less interoperability between affiliated organizations. Forward-thinking organizations are determined to remain profitable and at the forefront of patient care, regardless of the requirements.

There are several obstacles to the success of the ACO model, including overcoming patients who may see ACOs as a new form of HMO. If patients believe ACOs are going to restrict their choices simply to save money, the model will be met with oppo-sition, which is detrimental since a large part of ACO’s success depends on patients’ voluntary participation in preventative medicine.

There is little doubt that ACOs will alter the health care land-scape by changing the way health care providers measure suc-cess. Patient care will again become the main focus, placing the current fee-for-service model in the past, alongside HMOs.

Common IT Challenges of ACOs•Interoperability

• ACOs will dramatically increase interface demand to con-nect the patient data through the ACO workflow.

•Connectivity• ACO provider organizations will need to send data through

a shared, secure network. •EHR Record Analysis

• ACOs will need to leverage clinical IT for intensive care management and data analysis. Creating disease regis-tries will help caregivers and patients manage diseases to prevent emergency department visits.

•Emphasis on IT• ACO IT measures will need to be included in organiza-

tional strategic plans.

For more HIE resources, visit corepointhealth.com/START.

The many detractors of ACOs believe they are a utopian

big-government dream destined to fail .

IHE is a group of health care industry representatives that work to improve the way health care

systems share information electronically. The group was formed in 1998 as a cooperative venture

by the Healthcare Information and Management Systems Society (HIMSS) and the Radiologic Society

of North America (RSNA) with the goal to promote interoperability among imaging and health care

information systems. Today, IHE membership includes more than 200 global health care professional

associations and health care vendors.

IHE encourages the use of established interoperability standards such as HL7 and DICOM. Systems developed in accordance

with IHE communicate with one another better, are easier to implement and help health care providers use information more

effectively and, ultimately, provide better patient care.

What can ihe do for health it professionals?Creating interfaces between systems is a key challenge faced by many health care IT departments. Understanding the differing

implementation of standards in various vendor systems and creating a way to share information between those vendors is

challenging.

IHE offers a common framework for vendors and IT departments to understand and address clinical integration needs. IHE

Profiles, described below, are not just data standards, they describe workflows, which makes them more practical for use by

healthcare IT professionals and more applicable to their day-to-day activities.

Because IHE’s membership includes a wide array of end users, it focuses on solving relevant integration issues. These

solutions provide vendors with many benefits including:

• shorter, less costly implementations.

• Cross-system dataflow out of the box.

• smoother, complete workflows.

ihe profilesIHE strives to solve specific integration problems faced by its membership in the real world through Integration Profiles. These

profiles define the systems involved (i.e., actors), the specific standards used, and the details needed to implement the solution.

Each profile offers developers clear communication standards that have been reviewed and tested by industry partners.

Commonly used health it ihe profiles for interoperability

• XDm—CRoss-enteRpRise DoCument meDia inteRChange: WHat It’s usEd foR: according to IHE, xdM

transfers documents and metadata using Cds, usB memory or email attachments. this profile supports environments

with minimal capabilities in terms of using Web services and generating detailed metadata. this standard is utilized by

the direct Project.

ExaMPlE: using secure e-mail, a physician e-mails the patient’s CCd to the patient’s Microsoft Healthvault e-mail

account for uploading to the patient’s online PHR.

Health Standards: Integrating the Healthcare Enterprise (IHE)

by Rob Brull, Corepoint Health

Your Resource Center.

Go to HL7standards.com to read

practical insights and viewpoints.

• XDR—CRoss-enteRpRise DoCument Reliable inteRChange: WHat It’s usEd foR: the exchange of health

documents between health enterprises using a web-based, point-to-point push network communication, permitting direct

interchange between EHRs, PHRs and other systems without the need for a document repository.

ExaMPlE: a nurse at Hospital a enters a patient’s information in the local EHR, and then sends the CCd directly to Hospital

B’s system.

• XDs.b—CRoss-enteRpRise DoCument shaRing: WHat It’s usEd foR: the sharing of documents between any health

care enterprise, ranging from a private physician office to a clinic to an acute care in-patient facility, through a common

registry. Medical documents can be stored, registered, found and accessed.

ExaMPlE:

1. Hospital a has a document to store. Hospital a creates a description and metadata for the document and submits

it to the HIE Repository.

2. the HIE Repository accepts the document with metadata. It stores the document and forwards the metadata to

the HIE Registry.

3. the HIE Registry receives a query from Hospital B and identifies the document as a match based on the metadata.

4. Hospital B retrieves the document from the HIE Repository.

• XDs-i.b—CRoss-enteRpRise DoCument shaRing foR imaging: WHat It’s usEd foR: the sharing of images,

diagnostic reports and related information through a common registry.

ExaMPlE: a radiologist accesses the local HIE, in a similar manner as for xds.b, to find a MR report conducted and

uploaded to the HIE at Hospital a.

• pDQ – patient DemogRaphiCs QueRy: WHat It’s usEd foR: Requesting patient Id’s from a central patient information

server based on patient demographic information. used when a system has only demographic data for patient identification.

ExaMPlE: Hospital a admits Patient Y, who has not been at the hospital before. Hospital a submits a request to the local

HIE, based on demographic information such as name, birthdate, sex, etc., to obtain the appropriate HIE patient Id for

Patient Y

• piX – patient iDentifieR CRoss RefeRenCing: WHat It’s usEd foR: Cross-referencing multiple local patient Id’s

between hospitals, sites, health information exchange networks, etc. used when local patient Id’s have been registered

with a PIx manager.

ExaMPlE: Hospital a transmits Patient d’s Id information to the HIE for cross referencing. Hospital a receives Patient d’s

local Id for Hospital B which they can use to request information from Hospital B, based on need.

IHE Integration Profiles provide standards that address specific needs, eliminating ambiguities and ensuring a higher level of

practical interoperability. Because it encourages use of established healthcare standards such as HL7 and DICOM, IHE is in a unique

position to accelerate the process for implementing standards-based interoperability among electronic health records systems.

For more information visit: www.himss.org/ASP/topics_ihe.asp.

Questions

Joe MooreChief Information OfficerRadiology Consultants of Iowa

What changes do you see in radiology as ACOs unfold? Joe Moore: More confusion, turmoil and disruption. Imaging has a target on its back due to the increased utilization and skyrocketing costs.

In the government’s usual fashion, they avoid dealing directly with the cause and instead have chosen the route of making imaging less profitable. This will have little impact on those responsible since they will just order more tests, and imaging is not their core line of business. Radiologists on the other hand get all their revenue from imaging and will be affected significantly.

What do you believe the radiology IT priorities are for 2012? Moore: Position for survival. Radiology needs to be more flexible and embrace a service model that will

make them more vital. The industry of radiology is partly to blame for current trends toward outsourcing imag-ing to large, national groups. Radiology is now a 24x7x365 service and hospital administrators are increasingly

demanding more from their radiologists.

IT can prepare the practice for the transition to a more complete service model by ensuring their systems can support multiple orga-nizations, run on networks designed to distribute the workload across the enterprise, interoperate and integrate with many systems, and adapt to the changing landscape.

What technologies are exciting for radiology right now? Moore: The most exciting technology today, for my money, is cloud services and virtualization. These technologies support the pri-orities I mentioned above and are critical to our operation.

We’ve made a fair amount of progress in my organization virtualizing the data center and many of our desktops. We have what I con-sider an internal cloud. I look forward to the day when we can virtualize our PACS workstations, which will provide flexibility, cus-tomization, fault tolerance and efficiency.

External cloud services can best be utilized to offload common IT tasks such as spam, virus and web filtering, backup, disaster recovery and web hosting, thus allowing the internal IT to focus on technology that is unique to radiology. I don’t see us going fully to external cloud services any time soon, but certainly a hybrid model of both internal and external cloud services is the way to go.

Healthcare integration and interoperability have always been a strategic initiative for RCI. What new initiatives are you undertaking? Any HIe involvement? Moore: RCI is involved in a couple of HIE initiatives at the state and local level. We feel that to continue to add more value to our ser-vice, it is critical that we make our information available to all who need it, when they need it, in an appropriately secure fashion. I think we’ll have to support numerous avenues of integration and interoperability whether it be with PHRs, EHRs, HIEs or whatever else comes down the pike. This really leads back to our priority of being flexible and prepared for the known and unknown changes coming at us.

There are many new professionals joining the health IT profession. What advice would you give them? Moore: I would say the number one thing to focus on is the core business or core service you are supporting. Make sure you under-stand the point of view of the clinician.

This transformation isn’t similar to other industries. You have to remember that clinicians work impacts people’s lives. When you put a new application or process in their hands, it’s important to understand that many of them are horrified at the thought.

IT should be there to get clinicians over their anxiety and provide the training needed to use the new system to its fullest extent. Don’t take criticism personal and never assume you know what a clinician wants; most of the time the opposite is true.

Your success relies on clinicians’ successful use of applications and services. If the end users are miserable, you’re going to be mis-erable. Take pride in being a service provider. Too many in HIT see themselves at some higher level of intelligence because they work in a field that is a mystery to many.

Don’t think of the technology as the most important thing. Think about the end result, take pride in being a service provider and have some patience and respect for your end users.

BLOGFor insights on health IT, innovation, debates, and HITECH.corepointhealth.com/GENi

“Insights”

North Kansas City Hospital

North Kansas City Hospital, a 451-bed acute-care facility in the Kansas City

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at each step of the way,” said Kelley McFarland,

interface analyst at North Kansas City Hospital.

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since purchasing Corepoint Integration Engine

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Because it will always be necessary to move

health information from system to system,

inside and outside the hospital, North Kansas City Hospital plans to incorporate

Corepoint Integration Engine into future IT plans.

“One thing I really like, that makes it so easy to develop interfaces, is the abil-

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North Kansas City Hospital is one of the largest employers in the Kansas City

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totaling $13 million, followed in February by a $17 million project to renovate two

maternity floors.

Read the complete case study at corepointhealth.com/START.

“ Because it will always

be necessary to move

health information

from system to system,

inside and outside the

hospital, North Kansas

City Hospital plans to

incorporate Corepoint

Integration Engine into

future IT plans.”

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