As challenging as it is for the leaders of hospitals, medical groups and health systems to strategize broadly around the plunge into risk-based contracting, strategizing around the information technology foundations and data analytics to support that journey is turning out to be equally challenging. That is the verdict of leaders from across the spectrum of U.S. healthcare, and from the hospital, physician group, integrated health system, and health plan sides of the table.
Fundamentally, says Shawn Griffin, M.D., vice president, clinical performance improvement and applied analytics, at the Charlotte-based Premier Inc., “The response to risk is trying to increase control, and our data systems have not been organized to give us total control over processes. The challenge,” Griffin says, “is that your insurance company you’re contracting with controls and owns the data; data ownership is an important concept. And even doctors aren’t all on the same EHR [electronic health record], who are in the same network. And now that the system of care isn’t just hospitals, but outpatient and post-acute as well, you have to build data and IT governance” around participation in value-based healthcare contracting. “You have different metrics for different claims and clinical data types; and the fact that we’re trying to bring in different types of data and tell the same story with them, is difficult. And the lack of interoperability is a huge challenge," he says.
“I feel like we’re making progress on the claims data, because organizations are getting better at doing claims analytics; we’re now beginning to be able to use claims data to identify, for example, who the high-risk and high-cost patients are,” says Joe Damore, Griffin’s colleague and a vice president at Premier Inc. “But I still see a huge challenge in the lack of interoperability among EHRs. I don’t see anyone who’s mastered the situation yet of networks that are using multiple EHRs.”
“We have a sketch of interoperability that often involves dumbing down the information you share among EHRs. Almost nobody talks about claims interoperability,” Griffin adds. “Medicare Advantage versus commercial plans, multiple Medicare Advantage plans, all are different versions of claims data. We all have a phrasebook for a foreign language,” he adds.
Health plan leaders agree that there are some very fundamental challenges involved, including on the payer side. Speaking of the challenges for providers partnering with health plans, in marrying clinical and claims data, as well as simply in getting data to providers in a timely way, Chris Jaeger, M.D., vice president of accountable care innovation and clinical transformation at the San Francisco-based Blue Shield of California, says, “Having been on both the provider and plan sides, those are definitely real hurdles. It speaks to immaturity in master data management. And even when there’s more mature enterprise master data management, it will vary across organizations, so that’s a huge problem. And with respect to data timeliness, one challenge relates to plans sharing adjudicated claims data, where inevitably there’s a lag. On the provider side,” he adds, “my last experience was with PPO shared-savings contracts, and we had problems with timeliness and accuracy of data from plans, and sometimes just in terms of the master data management.”
What’s more, Jaeger says, data integrity remains a core challenge, in all situations involving health plans sharing data with provider organizations. “We were seeing data integrity issues that we needed to fix, before we could marry the plan data with our clinical data. And a lot of vendors will say they have the capability to deal with that, but the devil is in the details. So, we’ve been partnering with some of our provider partners, sitting down with them, with their resources, as well as with the partnering population health vendors, to improve how the data is moved and used, so they can do a better job.” What’s more, he says, “Data management doesn’t sound like a sexy value proposition, but it ends up being of incredible value. So really, if an organization is able to cleanse and aggregate data from multiple sources and bring the data into its analytics, you get better results.”
Getting Physicians Engaged in the Broader Effort
When it comes to getting physicians in practice engaged and motivated to support ACO (accountable care organization) and other value-based healthcare initiatives, the challenges are manifold, says R. Todd Richwine, D.O., chief medical informatics officer at the Texas Health Physicians Group, the 757-physician umbrella physician group attached to the Texas Health Resources integrated health system, which is based in the Dallas suburb of Arlington. Asked what he’s learned in the past few years around this, Richwine says, “Overall, that this is all too complicated. And that’s a big part of why I got into this role. When I came into our EHR from an older one that frankly was simpler and easier to use, I was astounded by the complexity, as an end-user. I went to a one-day conference, and our chief system clinical information officer said that we need to make the right thing, the easy thing to do. Doctors want to do the right thing, but if it’s too complicated, they’ll not do that. So, my guiding principle as CMIO has been to make the right thing the easy thing to do. We don’t want to add to the confusion or workload of physicians.”
Still, Richwine says, “I’ve really enjoyed” working with fellow physicians on clinical IT development around clinical performance improvement efforts. “As I’ve been able to go out to physician clinics and talk about improving quality measures, with rare exceptions, our physicians are interested and motivated to improve their outcomes, especially around chronic conditions like diabetes and hypertension; they very actively look for those patients who aren’t following up or who are falling outside the parameters on a regular basis. Once I show them the tools and techniques, they get very interested and get their teams involved in improving outcomes for those patients.”
“The success of value-based care can only come if your physicians are truly involved,” says Sohail, the CIO at the Dallas-based Premier Management Company, a firm that organizes and manages ACOs (and is unrelated to the Charlotte-based Premier Inc.). “And unless and until you are able to provide them no more than three actions they’re supposed to take, around a particular patient, in order to be successful clinically or financially, they’ll never be able to execute,” says Sohail (who uses one name only). “So keeping value-based care as simple as possible, and as smart as possible, is key, knowing that physicians have very limited time and are running on a treadmill, and building systems around them that can optimize their work, and show them that if they adopt the system, they’ll be successful, and if not, they won’t,” he says.
Meanwhile, fundamental IT foundational issues remain, says Premier Inc.’s Griffin. “You need interoperability to make this work, and interoperability requires connectivity, so you need to be fleshing out your connections with all your providers, and you need to get the wiring down. And you’ve got to be working with your physicians, and make sure your clinicians are at your table as your building out your plan, and solving problems, not just increasing responsibilities. There’s no magic bullet, but there are islands of competency, where leaders of patient care organizations are doing this well, and sharing information with others.”
What’s more, says Premier Inc.’s Damore, “I also think you need to take an interdisciplinary approach to governance of IT. The CMIO and CIO can lead that effort, but shouldn’t be doing it in isolation. You need clinicians, your quality leader, your financial leader, and your clinical integration leader. So you need multiple people at the table. And you need to develop a roadmap that’s logical.”
“I think the biggest piece that I’d point to is that, through all of the iterations around value-based healthcare, and various programs, etc., there really is a handful of core building blocks and common set of needs around familiarizing themselves with data aggregation, predictive analytics, and performance measurement,” says Laurie Sprung, Ph.D., vice president, consulting, at The Advisory Board Company, the consultative firm based in Washington, D.C. Given that, Sprung says, “Healthcare IT leaders need to familiarize themselves with those elements. And many technology people have a philosophy of how they want their technology infrastructure to look and how the pieces relate to each other. I get that, they want to rationalize all the elements. But if you start out focusing on where your organization needs to go with this, you’ll be better off, because the technology is not in its final form yet, so it’s not just what the technology does, but how it aligns with the building blocks of creating a value-based care delivery system,” she emphasizes.
Laurie Sprung, Ph.D.
And the IT leaders of organizations that are early on the journey into value-based healthcare are already learning important things, says Michael Restuccia, vice president and CIO at Penn Medicine, the multi-hospital system based in Philadelphia. “First and foremost,” he says, “we learned what the definition of a readmission was. And I think the institutional knowledge and agreement of what a readmission is and is not, was a big learning for us. And we learned that, at times, different parts of our organization had different definitions of it.” In other words, he says, “We’ve learned that we needed to standardize our definitions, in order to modify our behaviors. And the IT system is the glue that holds that together.”
“Organizations need to focus on enterprise data governance and data management, as a key capability that can be built up; and they need to take a leap of faith and begin trusting the health plans more, with respect to data sharing,” says Blue Shield of California’s Jaeger. “When I was on the provider side as a CMIO, and we started talking about sharing clinical data with plans, there was a lot of fear that the data would be used against us, in terms of competitive advantage we had in relation to competing provider organizations. So the key is to take that leap of faith and share data with health plans, understanding that the health plans have legal constraints with what they can do, too, with respect to HIPAA (Health Insurance Portability and Accountability Act of 1996). So focusing on value-based incentives and quality improvements, will help the people we’re both trying to help—the patients.”