Karen Bell, MD, MMS Director, Center for Sustainable Health and Care JBS International, Inc. Former Chair Certification Commission for Health Information Technology

1. HIT and Accountable Care

2. Today’s Objectives
1. Establish accountable care as foundational for reforming
health care
2. Establish HIT as foundational for accountable care
3. Introduce the consensus developed publicly available
ACO/HIT Framework www.cchit.org/hitframework
4. Suggest implementation approaches
5. Discuss the ACO Workgroup’s draft recommendations to
the HIT Policy Council regarding how HHS can better
support the accountable care environment

3. Historical Silos: Fragmented Care
Payer: Focus on Members
Costs, and Measures
• Contracts with multiple providers
• Benefits vary per member
• Available networks per member
• Claims (what was paid for)
• Diagnoses (on claims)
• Clinical data extracted for quality
measurement purposes (HEDIS) for
NCQA, PQRI, etc.)
• Emphasis on measurement
Providers: Focused on the
Patient and Internal Care
Workflows
• Reimbursed by multiple payers under
multiple contractual arrangements
• Cares for multiple patients with multiple
benefit structures/networks
• Cares for patients who see multiple
other providers
• Has information on care generated at
point of care only
Community Based Care:
Focused on Individual Needs
•Outcomes and goals
•End of life wishes, living wills, etc.
•Cultural preferences
•Health risks
•Public Health programs
•Patient monitored data
•Pastoral, social, familial caregiver supports
•Independent of payer or provider

4. The Goal of Health Reform
Patient
Focused
Health &
Care
ProvidersPayers
Community
based care

5. Basic Concepts: Patient Focused Care
• Emphasis on preventive as well as acute care
• Preventive care provided by teams
• Patients included in the teams
• Clinicians practice at top of their licenses
• HIT must be able to support diverse information
sharing across multiple constituencies
• Data management/analysis foundational
• Attention to social determinants of health
• Focus on outcomes

6. Getting There
• Changing Roles and
Responsibilities
• Value based vs Volume Based
Payment
• Instantaneous availability of
multiple types of Information

7. Changing Roles and Responsibilities
The Clinician of Record (legal responsibility)
• Usually a primary care physician/clinician
• Leads a primary care team that conducts follow up, monitoring, and
supports preventive care in and out of office
• Organizes and participates in a multi-specialty team if appropriate
with patient
The Specialist
• Provides counsel and services as appropriate for care
• Agrees to participate in patients’ team of care
The Organization
• Provides data management and analytical services
• Provides access to needed clinical information (HIE, links, etc.)
• Provides access to needed administrative information (networks,
benefits, ADT feeds, etc.)
• Contracts with aligned providers across the continuum of care

8. Why Focus on HIT for ACOs?
• Changing reimbursement policies: growing accountability
for cost, quality, and patient focused care
– Federal ACO/MSS rule
– Commercial insurers offering multiple types of ACO models
– Some states mandating accountable care from Medicaid
providers
– Over 500 providers groups in some form of financial risk
arrangement
• ACO payment different from HMO capitation of the 1990s
– Emphasis on quality of care as well as patient engagement
– No designated “gatekeepers” -- patients seek care where they
wish
– Care beyond the walls of the accountable provider(s)
• Information needed to support these and changing roles

9. Technology takes
you beyond
classic acute
clinical care
towards improved
health outcomes
• http://www.countyhealthrankings.org/our-approach

10. What is the ACO/HIT Framework
• Consensus driven, publically available set of
processes, functions, and HIT capabilities to
support transitions to and through the ACO
environment
• “Glide Path” for providers taking on greater
financial risk
• Tool to assess readiness for assuming risk for
costs, quality, and patient loyalty
• Discussion platform within an institution, among
institutions, for public policy

12. The Framework Part 1: Summary
• Represents a provider orientation -- how care
delivery functions at the organizational level
• Grounded in goals and objectives of care delivery
• Process oriented in the accountable care delivery
environment with necessary functions outlined for
each process
• Recognizes the importance of partnering with
payers, other providers, community based
organizations, and patients in achieving the goals
and objectives accountable care.

14. Important Consideration
• Emphasis on Primary HIT requirements
common to all organizations in the accountable
care arena and to all processes
– Sharing of health information – among providers internal and
external to organization as well as with patients and their
designated caregivers
– Data integration from multiple sources -- clinical, operational,
financial and patient derived
– Specific patient safety features
– Strong privacy and security protections
• Can be implemented in multiple ways
• Can be implemented by different partners

16. The Framework Part 2: HIT Capabilities
• Each process and its functions are defined in
detail
• HIT capabilities optimally supporting each of the
64 discrete functions are outlined
• Patient safety features are bolded
• MU 2014 criteria are starred

17. Care
Coordination
Care Coordination involves two different but related aspects of
patient care. One provides information to the clinician who must be
able to access from and provide relevant clinical data to multiple
sources in order to determine and provide for appropriate next steps
in diagnosis or treatment. The other is to assure that patients are in
the appropriate setting as they transition among multiple levels of
care. Both are important for providing high quality care as well as
mitigating excess, both must incorporate patient needs and
preferences, and both are highly dependent on the ability to quickly
and easily send and query health information on a given patient to
and from multiple electronic sources.

19. Framework Goal: Help Develop your own
ACO/HIT Glide Path aligned with your Goals
Focus Current Situation Transitioning
Environment
Transformed Future
Clinical Culture Physician centric,
individualistic,
authoritative
Primary care based
teams, may include
patient and designees
True collaboration with
all providers, patients
and designees
Cost Efficiency Cost measurement
based on silos of
payer claims
Care coordination and
care management
processes
Strong business
analytics, contracts and
improved clinical
processes
Reimbursement Incentive Mostly FFS, moving
into upside financial
risk
Significant up and
downside risk
Most patients under
global payment
arrangements
Patient Involvement Patient satisfaction
surveys (to the
patient)
Patient outreach and
follow up (for the
patient)
Patient as partners (with
the patient)
Quality of Care Reporting on a
myriad of measures
to a myriad of
entities
Manage specific cohorts
to individual goals
CQI based care process
reengineering

20. Major Challenges
Many provider groups simply not ready
– Insufficient capital
– Governance
– Inadequate HIT systems
– No opportunity for a PCMH base
– Lack of BH integration
– Not enough patients in risk contract
Payers not aligned
– Different contracting arrangements
– Different performance metrics and contracting arrangements
– Different attribution algorithms
– Different types of partnerships

21. Major Challenges
No access to available administrative data
– Full set of claims (total costs of care, financial management)
– ADT feeds
– Social determinants of health
– Real time Eligibility and Benefit information
Inability to exchange clinical data and information
– Within ACO environment
– External to ACO environment
– Telehealth
– Remote monitoring devices

22. • Decrease total costs of care: hospital
admissions, readmissions, and ER visits
• Improve your quality metrics: focus on specified
patient cohorts
• Improve patient satisfaction measures: engage
your cohort patients as much as possible, focus
on outcomes
Initiate HIT Supported, Patient Based
Population Health Management:
aka Cohort Management
Getting Started: Low Hanging Fruit

23. Critical Components of Cohort
Management
1. ID patients and cohort(s) (data and analytics)
• Predictive modeling for high cost patients (need all claims, patient
supplied, and clinical data)
• ID by procedures, dx, gender, age, meds, etc.
2. Prioritize your cohorts (data and analytics)
• Opportunities to decrease cost
• Opportunities to improve quality metrics
• The Scope/Resources/Time Triangle
• ROI analyses

24. Critical Components
3. CDS – HIT system support
• non intrusive, usable for clinician AND patient
• appropriate to cohort
• reliable, valid, accurate
4. Ability to monitor and flag events and results – HIT
system support
• Access to ADT feeds
• Specified milestones and goals
• Trending capabilities
• Applicable to all patients in a specified cohort

25. Critical Components
5. Patient Engagement – multiple HIT approaches
• Culturally appropriate information and educational materials
• Secure messaging, texting, etc.
• Capture data from remote monitoring devices
• Patient/caregiver access to own data and records
• Participation in team assessments and planning
6. Preferred Provider Engagement-referral network
• Include community based services
• Include all relevant specialties on team (BH)

26. Critical Components
7. Shared Careplans -- HIT system support
• Accessible by all providers as well as patient/caregiver,
including hospital staff as needed
• Includes patient specified goals and objectives
• Includes information on HC proxy and/or MOLST
8. Appropriate Interventions – HIT system support
• CPOE, ROE
• Access to up to date clinical reviews
• Incorporation of patient preferences
• Scheduling on behalf of the patient

27. Critical Components
9. Follow up – HIT System Support
• Record all results
• Notify clinician if appointment, test, procedure, medication not
obtained or kept
• Update careplans and monitoring applications
• Communicate with patient
10. Monitor the Cohort – Data Analytics
• Quality indicator goals being met
• Savings accrued
• Patient satisfaction
• Program costs

28. Attend to your Drivers
• Payment reform at all levels (clinicians)
• Robust Health Information Exchange
• Data access (claims, clinical, administrative,
patient reported, data on social determinants),
integration, analysis (monitor, predict, plan)
• Programs and processes for patient
management outside of the traditional delivery
system
• Culture change -- at all levels

29. Culture Change: Early Goals
Ambulatory Care
 Minimize Administrative Burden
 Establish Patient Centered Medical Homes
 Integrate BH (MH and SA) and Primary Care
Hospital:
 Minimize administrative burden
 Establish multi-disciplinary care teams
 Extend discharge planning through next
encounter

30. Five Components of Culture Change
• Simplify -- minimize clinicians’ administrative burden, do not add
to it; make it easy for patients to navigate your website, your campus,
and their specific encounters
• Inform – make it easy for clinicians and patients to find valid and
reliable information when they are looking for it (up to date topic
specific monographs); provide important information (PH alerts, drug
recalls, relevant clinical trials) on a regular basis
• Educate – using culturally appropriate methodology for patients and
non intrusive, informative, up to date CDS for clinicians
• Communicate -- secure messaging, texting, shared EHR
• Collaborate – incorporate patient (their designated caregivers) and
all members of their care team in relevant discussions and decisions;
create shared understanding of treatment goals and revisit them
frequently.

31. Sharing Clinical Information: Early
Goals
• Coordination of Care at the Primary Care level
• Safe handoffs during transitions of care
• Medication Reconciliation in both inpatient and
outpatient settings

32. Sharing Clinical Information
Within an accountable care organization
 Same EHR, same implementation
 Cross-viewing
 Portal technology and a Clinical Data Warehouse
 Community Based HIE
With external providers
 Community Based HIE
 Cross-viewing
 LAND and SEE technology
With patients
 Patient portals
 Secure messaging
 Texting
 Remote monitoring devices

33. Data Access: Early Goals
• Compute total costs of care for attributed
patients, track financials
• Predictive modeling (ID cohort appropriate
patients)
• Track quality measurements
• Know when and where your patients are getting
their care

34. Data Access
Create a data warehouse (quality reporting, basic
analytics, predictive modeling)
Negotiate with payers (APCD if you have one)
• Total claims data on your attributed patients (total costs of
care)
• Eligibility and benefit feeds from payers (networks, co-
pays, deductibles, etc.)
Negotiate with other providers/HIE
• ADT feeds
• Use of a shared care plan

35. Data Access, Integration, Analysis
Claims -- All payer data bases (including BH)
 Total costs of care, program evaluation, risk sharing
algorithms
 Business Intelligence Analyses
– Descriptive – reports, dashboards, trends, monitoring, etc.
– Predictive – applied statistics and modeling to identify priorities
– Prescriptive – linear programming and regressions to analyze options
 Attribution algorithms, leakage, alternative payment methods
Social Determinants of Health
 Data from multiple state agencies and departments
Community based programming
 Population needs assessments
 Program development and assessment
 Patient derived outcomes data

36. Payment Reform: Early Goals
Only take on financial risk than you can handle
• Upside risk only (MSSP, PCMH bonus, P4P)
• Up and down side risk -- if you can do it for about 30% of your
patient population
• Global budgets, capitation, bundled payments -- not until you’ve
proven successful in less risky contracts
Consider other than FFS/productivity remuneration
for clinicians, especially specialists
Include care outside of the office setting in
remuneration formulae

37. The ACO Workgroup
• Reports into the Federal HIT Policy Committee to
HHS
• Meetings based on ACO/HIT Framework June-
November
• Public Testimony: December 5, 20113
• Recommendations due Q1 2014
• Objective:
How can HHS (writ large) policies and programs
better support innovative approaches in the AC
environment, particularly with respect to HIT?

38. Recommendations in Discussion:
CMS Support to Adopt Robust HIT
• Increase up front funding for MSSP or funding for
including partners not eligible for MU
• Require 50% of PCPS to have met at least MU stage
1, particularly for two sided risk
• Require plan to integrate BH and physical health, using
HIT
• Require “Glide Path” Plan
• Require commitment from external care partners to
share clinical information electronically on mutual
patients

39. Recommendations in Discussion:
Access to Administrative Data
Claims
• Support APCDs in every state through the SIM grant mechanism
• Release Medicare BH claims data
• Release Medicare claims data to potential MSSP applicants
• Explore how to integrate with clinical data
• Encounter data
• HL7 standards and scalable architecture for ADT notifications to ACOs
SDH
• Convene PH stakeholders to develop SDH markers for accountable care
• Support intra-state collaboration among multiple agencies and departments
Eligibility and Benefits
• Make Medicare and Medicaid E and B data available 24/7 to guide cost
effective, patient centered referrals for care. Encourage commercial insurers
to do the same.

40. Recommendations in Discussion:
Sharing Clinical Information
Policy and Strategy
• SAMHSA to issue guidelines to clarify issues re sharing BH data and work with OCR, CMS,
and ONC to modify CFR 42 if necessary to optimize care
• CMS to use survey and cert program to review timely transfer of data to care partners
• HHS to create a suitable measure for institutions sharing data and report on Compare Website
• HHS to seek ways to mitigate difficulties with institutions not willing to share clinical data
• Strengthen measures around cross vender exchange for future MU stages
• Federal ACOs must participate in local/regional/state HIE if available
Technology (Data Liquidity)
• More specificity for interoperability standards for data beyond currently required
• Develop a common API for HIT applications to allow real time data sharing
• Develop and promulgate a voluntary testing and certification program limited to interoperability
for all types of HIT
• Retract ONC Certification of vendors who do not implement HIE capacity in the provider setting

41. Recommendations in Discussion:
Use of Data
• Accelerate progress toward a universal approach to
shared care plans (and make use part of future stage of
MU? through testing of pilots
• Bring transparency to the operative characteristics of
predictive modeling tools to identify high risk patients
• Develop a standardized algorithm for determining
attribution and encourage its use by all payers
• Measure effectiveness of CDS for improvement purposes
• Integrate data from multiple sources to increase sensitivity
and specificity in triggering CDS alerts

42. Recommendations in Discussion:
Administrative Simplification
Streamline quality reporting
• Align all HHS agencies and departments with respect to quality metrics
• Lead commercial payers to align measure with HHS
• Create a single quality measure repository that reflects all payers’ measures
• Assure that all measures can be calculated from existing electronic data
• Integrate claims and clinical data
HIT Standards for Administrative procedures (e.g., prior authorization,
referrals, care necessity attestations)
CMS to review burden and value of all documentation requirements

43. Thank You!
Access to the interactive CCHIT ACO HIT
Framework with User’s Guide
www.cchit.org/hitframework
Contact: Karen Bell MD. MMS
Former Chair, Certification Commission for HIT
ACO Workgroup member (HIT Policy Committee)
Director, JBS Center for Sustainable Health and Care
kbell@jbsinternational.com
781-801-4145 (cell)
617-834-4213 (office)