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With the release of the Accountable Care Organization (ACO) regulations, healthcare providers must be able to identify, access, and seamlessly share patient information to drive efficiencies and enjoy a potential share in ACO program incentives. Additionally, more than half of the 93 draft National Committee for Quality Assurance (NCQA) ACO measures are also Meaningful Use measures, which further elevates the need to achieve meaningful use stage 2 or higher. Given these goals, success will ultimately depend on an organization’s ability to share patient data at the point of care and its ability to gain meaning from historical and longitudinal data for use in managing population health. Healthcare organizations will need to give focused attention to the IT strategies, appropriate architectures, and roadmaps they will use to move from desired state to reality. We discuss the practical architectural approach for creating an ACO. As Health Information Exchanges (HIEs) evolve into their second generation, they are able to the support the functional ACO tasks of delivering and managing care for a defined population, accept payment, distribute savings to participants, and perform disease management with predictive modeling to improve outcomes. We will also discuss the need to achieve meaningful use stage 2 or higher and the data/analytics requirements for ACO participants. Presenter Martin Sizemore is the Director of Healthcare Strategy for Perficient. Martin has been a consultant and trusted advisor to CEOs, COOs, CIOs and senior managers for global multi-national companies and healthcare organizations, and is a certified Enterprise Architect with specialized skills in Enterprise Application Integration (EAI) and Service Oriented Architecture (SOA).
Citation preview
ACO = HIE + Analytics
Martin SizemoreDirector, Healthcare Strategy
November 10, 2011
About Perficient
Perficient is a leading information technology consulting firm serving
clients throughout North America.
We help clients implement business-driven technology solutions that
integrate business processes, improve worker productivity, increase
customer loyalty and create a more agile enterprise to better
respond to new business opportunities.
PRFT Profile
Founded in 1997
Public, NASDAQ: PRFT
2010 Revenue of $215 million
20 major market locations throughout North America— Atlanta, Austin, Charlotte, Chicago, Cincinnati, Cleveland,
Columbus, Dallas, Denver, Detroit, Fairfax, Houston, Indianapolis, Minneapolis, New Orleans, Philadelphia, San Francisco, San Jose, St. Louis and Toronto
1,500+ colleagues
Dedicated solution practices
500+ enterprise clients (2010) and 85% repeat business rate
Alliance partnerships with major technology vendors
Multiple vendor/industry technology and growth awards
Perficient brings deep solutions expertise and offers a complete set of flexible services to help clients implement business-driven IT solutions
Our Solutions Expertise & Services
Business-Driven Solutions• Enterprise Portals• SOA and Business Process
Management• Business Intelligence• User-Centered Custom Applications• CRM Solutions• Enterprise Performance
Management• Customer Self-Service• eCommerce & Product Information
Management• Enterprise Content Management• Industry-Specific Solutions• Mobile Technology• Security Assessments
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Perficient Services End-to-End Solution Delivery IT Strategic Consulting IT Architecture Planning Business Process & Workflow
Consulting Usability and UI Consulting Custom Application Development Offshore Development Package Selection, Implementation
and Integration Architecture & Application Migrations Education
Our Speaker
Martin Sizemore• Enterprise Architect with specialized skills in Enterprise
Application Integration (EAI) and Service Oriented Architecture (SOA).
• Martin has been a consultant and trusted advisor to CEOs, COOs, CIOs and senior managers for global multi-national companies and healthcare organizations.
• His deep industry experience as a consultant in manufacturing, healthcare and financial services industries has provided him with a broad knowledge of IBM hardware and software offerings with numerous certifications and recognitions from IBM including On-Demand Computing and SOA Advisor.
• He is experienced with Microsoft general software products and architecture, including SharePoint and SQL Server and has worked closely with Microsoft architects on healthcare products including their healthcare CRM, Amalga, and HealthVault offerings.
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Agenda
• Accountable Care Organizations (ACO)• Definition, key components• ACO: Definition of success• ACO HIE requirements – use cases• HIE Current and Emerging views• ACOs require more than EHRs• Challenges to widespread ACO adoption• ACO = HIE + Analytics – Architecture• What are the typical use cases?• Summary
Accountable Care Organization-a definition
• A healthcare delivery system whose members share responsibility, financial risk and a common goal to improve healthcare delivery and the overall health status for a given population.
• Acts collaboratively to coordinate patient care across the continuum and share both the payment and responsibility for quality of care for the covered patients.
• Paid a specified amount for the population it manages, rather than a per transaction fee. ACOs can be incented if their quality and patient satisfaction scores are higher than expected; they can also receive decreased reimbursement if scores are lower than expected.
* HIMSS ACO FAQ, www.himss.org
Key components of an ACO
• Patient centered medical homes‐• Primary care physicians• Specialists• Minimum of one hospital• Ancillary providers• Minimum of 5,000 Medicare beneficiaries (for Medicare
demonstration funding)• Care coordination ability and mechanisms to support• Payer partnerships with reimbursement based on quality,
efficiencies and patient satisfaction
*Source: Article by Stephen M. Shortell and Lawrence P. Casalino
Emerging ACO Models Governance‐
Model Characteristics Current ExamplesIntegrated delivery systems/networks(IDN)
• Own hospitals, physician practices, perhaps an insurance plan.
• Aligned financial incentives.• E-health records, team-based care.
• Geisinger Health System• Group Health Cooperative of Puget Sound• Kaiser Permanente• Summa Health System
Multispecialtygroup practices(MSGP)
• Usually own or have strong affiliation with a hospital.
• Contracts with multiple health plans. • History of physician leadership. • Mechanisms for coordinated clinical care.
• Cleveland Clinic• Marshfield Clinic• Billings Clinic• Virginia Mason Clinic
Physician-hospitalorganizations(PHO)
• Nonemployee medical staff.• Function like multispecialty group practices.• Reorganize care delivery for cost-
effectiveness.
• Greater Newport Physicians (partners with Hoag)• St. Vincent Healthcare in Billings• Methodist LeBonheur Healthcare• Kettering Health Network
Independent Practice Associations
• Independent physician practices that jointly contract with health plans
• Active in practice redesign, quality improvement.
• Atrius Health (eastern Massachusetts)• Hill Physicians Group (southern California)• Monarch HealthCare (southern California)
Virtual Physician Organizations
• Small, independent physician practices, often in rural areas.
• Led by individual physicians, local medical foundation, or state Medicaid agency.
• Structure that provides leadership, infrastructure, resources
• Community Care of North Carolina• Grand Junction (Colorado)• North Dakota Cooperative Network
ACO: Definition of Success
Experience of Care
Per Capita Costs
Population Health Metrics:
• QUEST outcomes• Select HEDIS metrics• Health status – SF12• Mortality rates
Metrics:• Total medical PMPM• Total Medical Trend• Total Rx PMPM• Admissions/1000• Readmission rate
Metrics:• Patient satisfaction• PAM Scores (Patient Activation
Measures)
Improving triple aim™ population outcomes
* The term triple aim is a trademark of the Institute for Healthcare Improvement
Healthcare Business Intelligence will be the key to success in managing to these
metrics
Health Information Exchange (HIE)
• Extension of EMRs• Integration or
Interoperability role
• Primarily data push or pull
• Struggles with financial viability
• Shifting from state-level efforts to private HIEs
• Key element in the integration and coordination of care
HIE: Current View
Rx Claims
Medical Claims
Remote monitoring
Environmental
Social /economic
Lifestyle / behavioral
HRA
Bio-metrics
Labs
Demographics
HealthInformation
Exchange
Focus: Data collection and
Integration
Rx Claims
MedicalClaims
RemoteMonitoring
EnvironmentalFactors
Social /Economic
Lifestyle /Behavioral
HealthAssessments
Biometrics
Labs
Demographics
HIE: Emerging ACO View
Financial Performance
Clinical Performance
Risk / predictive modeling
Care plan design
Care plan deployment
Interventions
Quality Reporting
Risk Management
HealthInformation
ExchangeFocus: Population
Health Analysisand tracking
Financial Performance(vs. paid claims)
ClinicalPerformance
Risk / PredictiveModeling
Care PlanDesign Care Plan
Deployment
Interventions
QualityReporting
RiskManagement
ACOs require far more than EHRs
Requirements– Predictive modeling– Registries– EHR interfaces– Reminder systems– Claims and clinical data
warehouses– Episode of care analysis systems– Specifications for integrated
claims and clinical databases– Patient portal options– Health information exchanges
Data Sources for Mining– Medical records– Clinical outcomes data– Patient billing systems– Payer data– Quality measures abstracts– Charge master– Physician, payer, service line
utilization data– Infection surveillance data– Labor, productivity and
throughput records– Adverse drug events
Challenges to widespread ACO adoption
• Silos lead to a disconnected business and IT infrastructure• Islands of computing create inefficiencies and underutilized
assets• Missing or competing data standards, limited interoperability• Struggle with regulatory compliance, volume of information,
data integrity and security• Resource constraints and difficulty managing
complexity/change• Volume of data points and quality measures, in widely
dispersed locations• Limited use of analytics among providers
Moving beyond Operational Analytics
Based on: Competing on Analytics, Davenport and Harris, 2007Degree of Complexity
Com
petiti
ve A
dvan
tage
Standard Reporting
Ad hoc reporting
Query/drill down
Alerts
Simulation
Forecasting
Predictive modeling
Optimization
What exactly is the problem?
What will happen next if …?
What if these trends continue?
What could happen…. ?
What actions are needed?
How many, how often, where?
What happened?
Stochastic Optimization
How can we achieve the best outcome?
How can we achieve the best outcome including the effects of variability?
Operational AnalyticsSupport ongoing business operations
Meet compliance requirements
Advanced Analytics Prescriptive and Predictive
Support new business models and opportunities
Critical Business QuestionAnalytic Technique
Healthcare increasingly will use advanced analytics to drive clinical and operational improvements to meet business challenges
ACO: High Level Architecture
ACO Performance Management will be the key to success
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Transaction RepositoryAllergies
Billing
Lab Orders & Results
Medications
Encounter
Diagnosis
Procedures
Surgery
Survey
R&D
Others
Ente
rpris
e Se
rvic
es B
ackb
one
(HL7
/CCD
)
Patient
Provider
Clinical
Pharmacy
Billing
EMR’s
Claims
Registeries
Eligibility
Other
Taxonomy SnoMed , RxNorm, etc.
Data Modeling/ Metadata Management
Data Quality Management
Identity Management & Security
Infrastructure Services
Governance
Data Sources
Multi-tenant
Data Marts
Extract Routines
Org
aniz
ation
CHF
COPD
Other
Registries.
Asthma
Diabetes
CampaignsPurp
ose
Spec
ific
Cubes
Core Warehouse
Clinical
Financial
Operational
Claims
Health Info. Exchange
Reference Data
Patient Registry (EMPI)
Provider Registry
Organization Registry
Identity Resolution Hubs
Disease Registers
Data Mapping and transport
Business Intelligence & Population Services
Patient Services
Ad-Hoc Analysis
Standard Reporting
Care Notifications
Provider Messages/Services
HIE Services
(CCR/CDA/etc)
Campaign Services
Business Access Services
Contact Services
Cohort Services
Publish / Subscribe
Enterprise Information Portal (EIP)
Schedule Reports
HIE Portal
Query Tool
Personalize / Share Reports
Ente
rpris
e Se
rvic
es B
ackb
one
(HL7
/CCD
)
Use
r Acc
ess
Met
hods
Syst
em A
cces
s M
etho
ds
Web Portal
Email, SMS
Excel, PDF
Fax, Printer
Other
Message Bus
File Delivery
Data Extracts, FTP
Internal
Patient Portal
Physician Portal
Management
Information DeliveryInformation Consumers
Campaign Management
Community
Health
Research
Data Warehouse and Data Marts
Bi-d
irecti
onal
Inte
rfac
esIntegration
Reference (Terminology) HUB
Data Validation
Data Quality Metrics
Data, Transform and Load
Data
Standardization
Unified Standard Code Sets (HLI, UMLS)
Local Code Sets
ACO = HIE + Analytics: Architectural View
Physician Community
Groups
HIE + Analytics: What are typical use cases?
Use Cases Use Cases
Determine and model total cost of care across all settings (acute, ambulatory, home care) by population or individual
ID risk to patients by looking at environmental factors e.g. asthma, flu breakout
Care coordination New age case management (CRM for patients)
Match payer and provider data-verify rollout of preventative programs
ID labor savings. Correlate staffing to predicted demand/activity
Meds Mgmt./Reconciliation/Med Therapy Mgt./Prescription fill compliance
Physician attribution and/or care team – quality outcomes – patient satisfaction
Analyze population health levels based on various grouping (geo, facility, provider, etc.)
Monitor and track (real time) compliance to regulatory and/or clinical guidelines across settings
Understand resource utilizing productivity, throughput and access
Chronic care cost modeling to support payments and allocation
Evaluate readmission across continuum Support transitions of care through transfer of data
Resource planning/physician profitability (contract management, preferences, outcomes
Aggregate and manage data across all care settings (cost, care)
Support 65 ACO measures Comparative Effectiveness / waste reduction
Monitor/track patients experience beyond HCAPS (coordinate w/workforce, predict experience)
Creation of new evidence base for guidelines
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Why build this level of technical architecture?
• Move from retrospective reporting to predictive modeling of population health
• Create the data analytics necessary to move to evidence-based medicine and modeling of outcomes
• Predictive modeling provides an objective assessment of a patient’s future illness burden and associated health costs based upon their historical conditions as captured through claims and clinical information – key to ACO success!
– It is a method for prioritizing members for population health management and care management and stratifying them based upon their morbidity burden and financial risk
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Metadata is VERY important
ETL Operational Metadata (Job Run Information)
Physical Schemas
ETL Job Design
BI Reports
Business Glossary & IS Users
Industry Data Models
DW Design Model
Data Lineage is the key to integrity and troubleshooting
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Advanced Analytics Architecture
Cognos
Operational Source SystemsStructured / Unstructured Data
COMMON METADATA : Data Glossa
ry
Encryption – Data at R
est
Spreadsheets
Applications
Data Staging
Federated Data
Cubing Services
Data DefinitionGlossary
SOA Web Service
Master Data Management
Business Rules Engine
Common DefinitionManagementDeployment
Dashboards
Embedded Analytics
Financial Planning
Mash ups
Scorecards
• Data Integration • Data Quality • Data Delivery
Integrated Warehouse
Data RepositoryMultidimensional Analysis Data Mining
TerminologyServices
EMPI
Archive
Healthcare Information Exchange Appliance
• HL7 Acquisition• Routing• Remote Configuration & Monitoring
PresentationLayer
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ACO = HIE + Analytics Summary
Benchmarking Outcome AnalysisACO Analytics and Management
Population HealthManagement
Spend Analysis
Value Based PricingClaims Adjudication
Value Analysis
Quality
Labor Supply OptimizationSupply Chain Optimization
Waste and Harm
Operations ManagementOptimization
Efficiency & Effectiveness Analysis
Disease Management
Practitioner Profiling & Quality HEDIS 2010 (select measures)
Savings OpportunitiesHarm Avoidance
Safety Pharmacy Analysis AHRQ
Harm AvoidanceAlerting
Actuarial Analysis
Claims HandlingClaims Adjudication
P4PPatient SatisfactionPerformance Improvement
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To enable a smarter healthcare system that offers better care,
better value and better health.
To get the big picture and truly use healthcare IT to improve care in real time, our systems must enable care teams to:
– Access a patient’s medical history from a secure, yet accessible cloud.
– View anything and everything that could have an impact on a patient’s care, including past procedures and past medications.
– Review evidence-based examples of how to customize and tailor treatments to produce the best possible outcomes for individual patients.
– Evaluate whether treatments are effective over the long term and compare results with other providers.
– Balance the privacy interests of each patient and the societal benefits of greater access to powerful, aggregated intelligence.
Poll Question
What is the most important reason for analytics in an ACO?
A. Manage costs and operational efficiencyB. Manage population health including chronic illness C. Clinical research on best practices D. All of the above
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Q & A
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