ACO = HIE + Analytics. An ACO requires health information exchange capabilities to integrate clinical and claims data from various sources. It also requires advanced analytics to enable predictive modeling, population health management, and performance tracking against metrics like quality, costs, and health outcomes. The combination of HIE and analytics provides ACOs with insights needed to improve care coordination, reduce costs, and enhance overall population health.

1. ACO = HIE + Analytics
Martin Sizemore
Director, Healthcare Strategy
November 10, 2011

2. About Perficient
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clients throughout North America.
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5. 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.
5

6. 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

7. 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

8. 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

9. Emerging ACO Models ‐ Governance
Model Characteristics Current Examples
Integrated delivery • Own hospitals, physician practices, perhaps an • Geisinger Health System
insurance plan. • Group Health Cooperative of Puget Sound
systems/networks
• Aligned financial incentives. • Kaiser Permanente
(IDN) • E-health records, team-based care. • Summa Health System
Multispecialty • Usually own or have strong affiliation with a • Cleveland Clinic
hospital. • Marshfield Clinic
group practices
• Contracts with multiple health plans. • Billings Clinic
(MSGP) • History of physician leadership. • Virginia Mason Clinic
• Mechanisms for coordinated clinical care.
Physician-hospital • Nonemployee medical staff. • Greater Newport Physicians (partners with Hoag)
• Function like multispecialty group practices. • St. Vincent Healthcare in Billings
organizations
• Reorganize care delivery for cost- • Methodist LeBonheur Healthcare
(PHO) effectiveness. • Kettering Health Network
Independent Practice • Independent physician practices that jointly • Atrius Health (eastern Massachusetts)
contract with health plans • Hill Physicians Group (southern California)
Associations
• Active in practice redesign, quality • Monarch HealthCare (southern California)
improvement.
Virtual Physician • Small, independent physician practices, often • Community Care of North Carolina
in rural areas. • Grand Junction (Colorado)
Organizations
• Led by individual physicians, local medical • North Dakota Cooperative Network
foundation, or state Medicaid agency.
• Structure that provides leadership,
infrastructure, resources
*Source: Article by Stephen M. Shortell and Lawrence P. Casalino

10. ACO: Definition of Success
Experience Metrics:
Improving triple aim™ • Patient satisfaction
of Care • PAM Scores (Patient Activation
population outcomes Measures)
Per Capita Metrics:
• Total medical PMPM
Costs • Total Medical Trend
• Total Rx PMPM
• Admissions/1000
Population • Readmission rate
Metrics:
Health • QUEST outcomes
• Select HEDIS metrics
• Health status – SF12
• Mortality rates
Healthcare Business
Intelligence will be the key to
success in managing to these
metrics
* The term triple aim is a trademark of the Institute for Healthcare Improvement

11. 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

12. HIE: Current View
Demographics
Rx Claims
Demographics Rx Claims
Labs Labs Medical Claims
Medical
Claims
Health
Information
Biometrics Bio-metrics
Exchange Remote
monitoring
Remote
Monitoring
Focus: Data
collection and
Health Integration
HRA Environmental
Environmental
Assessments Factors
Lifestyle / Social
behavioral /economic
Lifestyle / Social /
Behavioral Economic

13. HIE: Emerging ACO View
Risk Financial Performance
Risk Financial
Management Management Performance (vs. paid claims)
Quality
Reporting
Quality
Reporting
Health Clinical
Performance
Clinical
Information Performance
Exchange
Focus: Population
Interventions
Health Analysis Risk /
predictive
and tracking modeling Risk / Predictive
Interventions Modeling
Care plan Care plan
deployment design
Care Plan
Care Plan
Design
Deployment

14. ACOs require far more than EHRs
Requirements Data Sources for Mining
– Predictive modeling – Medical records
– Registries – Clinical outcomes data
– EHR interfaces – Patient billing systems
– Reminder systems – Payer data
– Claims and clinical data – Quality measures abstracts
warehouses – Charge master
– Episode of care analysis systems – Physician, payer, service line
– Specifications for integrated utilization data
claims and clinical databases – Infection surveillance data
– Patient portal options – Labor, productivity and
– Health information exchanges throughput records
– Adverse drug events

15. 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

16. Moving beyond Operational Analytics
Healthcare increasingly will use advanced analytics to drive clinical and
operational improvements to meet business challenges
Analytic Technique Critical Business Question
How can we achieve the best outcome
Stochastic Optimization including the effects of variability? Advanced Analytics
Prescriptive and
Optimization How can we achieve the best outcome?
Predictive
Predictive modeling What will happen next if …? Support new business
models and opportunities
Forecasting What if these trends continue?
Simulation What could happen…. ?
Alerts What actions are needed?
Operational Analytics
Competitive Advantage
Query/drill down What exactly is the problem? Support ongoing business
operations
Ad hoc reporting How many, how often, where? Meet compliance
requirements
Standard Reporting What happened?
Degree of Complexity
Based on: Competing on Analytics, Davenport and Harris, 2007

17. ACO: High Level Architecture
ACO
Performance
Management
will be the key
to success

18. ACO = HIE + Analytics: Architectural View
Data Mapping and Data Warehouse Business Access Information
Data Sources Integration Health Info. Exchange Information Delivery
transport and Data Marts Services Consumers
Data Marts Business Intelligence & Enterprise Internal
Clinical Population Services Information Web
Transaction Repository
Patient Financial
Portal (EIP) Portal Physician
Allergies
Organization
Standard Reporting Portal
Billing Operational
Email,
User Access Methods
Lab Orders & Results Data Publish /
Provider Claims SMS
Medications Subscribe
Standardization Ad-Hoc Analysis Patient Portal
Encounter Core Warehouse
Diagnosis Excel,
Clinical Cubes PDF
Procedures
Bi-directional
Patient Services
Enterprise Services Backbone (HL7/CCD)
Surgery
Enterprise Services Backbone (HL7/CCD)
Schedule
Interfaces
Survey Reports Fax,
Pharmacy Printer
R&D
Care Notifications Management
Others Data Validation
Disease Registers
Billing Personalize / Other
Campaign
Provider Messages/Services Share
Management
CHF Asthma Reports
Identity Resolution Hubs
Purpose
Specific
EMR’s Community
Patient Registry (EMPI) COPD Diabetes HIE Services
Health
Provider Registry Data, Transform Other (CCR/CDA/etc)
Claims Campaigns Query Tool
and Load Registries. Data
Research
System Access Methods
Organization Registry Extracts
Campaign Services , FTP
Registeries Physician
Reference (Terminology) HUB Community
Contact Services Groups
Unified Standard Code HIE Portal Message
Sets (HLI, UMLS) Bus
Eligibility Data Quality Extract
Metrics Routines
Local Code Sets
Cohort Services
File
Other Reference Data Deliver
y
Taxonomy SnoMed , RxNorm, etc.
Data Modeling/ Metadata Management
Data Quality Management
Identity Management & Security
Multi-tenant
Infrastructure Services
Governance

19. HIE + Analytics: What are typical use cases?
Use Cases Use Cases
Determine and model total cost of care across all settings ID risk to patients by looking at environmental factors e.g.
(acute, ambulatory, home care) by population or individual asthma, flu breakout
Care coordination New age case management (CRM for patients)
Match payer and provider data-verify rollout of ID labor savings. Correlate staffing to predicted
preventative programs demand/activity
Meds Mgmt./Reconciliation/Med Therapy Mgt./Prescription Physician attribution and/or care team – quality outcomes
fill compliance – patient satisfaction
Analyze population health levels based on various Monitor and track (real time) compliance to regulatory
grouping (geo, facility, provider, etc.) and/or clinical guidelines across settings
Understand resource utilizing productivity, throughput Chronic care cost modeling to support payments and
and access allocation
Evaluate readmission across continuum Support transitions of care through transfer of data
Resource planning/physician profitability (contract Aggregate and manage data across all care settings (cost,
management, preferences, outcomes care)
Support 65 ACO measures Comparative Effectiveness / waste reduction
Monitor/track patients experience beyond HCAPS Creation of new evidence base for guidelines
(coordinate w/workforce, predict experience)
19

20. 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

21. Metadata is VERY important
Data Lineage is the key to integrity and troubleshooting
Business Glossary & IS Users ETL Operational Metadata (Job Run Information)
BI Reports
Physical Schemas
Industry Data Models
DW Design Model
ETL Job Design 21
21

22. Advanced Analytics Architecture
Presentation
Layer
Embedded
Master Data Management Analytics
Business Rules Common
Definition Dashboards
Engine Management Cogno
Deployment s Applications
Federated Data Mash ups Spreadsheet
SOA Web s
Service Financial
Planning
Integrated Scorecards
Terminology
Warehouse
Services
Cubing Services
Healthcare Information
Exchange Appliance
• HL7 Acquisition Data Repository
• Routing Multidimensional Data Definition
• Remote Analysis Glossary
Configuration & Data Mining Archive
Monitoring Data Staging
• Data Integration EMPI
Operational Source Systems • Data Quality
Structured / Unstructured Data • Data Delivery
22

23. ACO = HIE + Analytics Summary
Safety Pharmacy Analysis Harm Avoidance
AHRQ Alerting
Quality Practitioner Profiling & Quality P4P
HEDIS 2010 (select measures) Patient Satisfaction
Performance Improvement
Waste and Operations Management Savings Opportunities
Harm Optimization Harm Avoidance
Population Benchmarking Efficiency & Effectiveness
Health Outcome Analysis Analysis
Management ACO Analytics and Management Disease Management
Value Analysis Value Based Pricing Actuarial Analysis
Claims Adjudication
Spend Analysis
Labor Supply Optimization Claims Handling
Supply Chain Optimization Claims Adjudication
23

24. 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.
24

25. Poll Question
What is the most important reason for analytics in an
ACO?
A. Manage costs and operational efficiency
B. Manage population health including chronic illness
C. Clinical research on best practices
D. All of the above
25

26. Q&A

27. Join Perficient at HIMSS 2012
Healthcare IT Conference & Exhibition
February 20th – 24th
Venetian Sands Expo Center, Las Vegas
Visit us in Booth No. 1274 to speak to our
healthcare technology experts on:
• Business Intelligence & Analytics
• System Interoperability
• Health Information Exchange
• Portal Collaboration
• Regulatory Compliance
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