Supporting ACOs

Gregory J.
Raglow,
M.D.

There is no question that this is a time of uncertainty for healthcare organizations, with many difficult questions being raised in regard to health information exchange (HIE), accountable care organizations (ACOs) and more. Two things, however, are clear.

The first is that specific outcomes, quality processes and cost-performance standards for value-based programs will continually evolve. The second is that provider organizations will have to adapt to stay in business.

In this shifting environment, the non-profit Banner Health system already has begun aligning its strategic initiatives with HIE and ACO goals. We have come to recognize the importance of developing a process for innovation, devising a two-pronged approach that addresses how to: connect multiple healthcare organizations for optimal data exchange; and support employed and non-employed physicians toward common accountable care goals.

While Banner’s ACO strategy is still in its formative phase, emphasis is being placed on creating processes and IT infrastructure flexible enough to support both internal and external requirements as they develop. A phased approach is being employed.

The health system itself comprises 23 hospitals and numerous physician services locations across seven states. The first step in our strategy, therefore, was to bring all of our hospital organizations onto a unified EHR platform. We are midway through the process now of implementing the second step: expanding to bring more than 800 employed physicians in 150 locations live on the platform as well. At the same time, we have implemented an HIE platform, which goes live concurrently with the EHR.

Both the inpatient EHR and the ambulatory EHR are configured as an “enterprise chart,” such that providers taking care of a patient in either setting have access to the entire record (with some exceptions for things such as behavioral health). The HIE allows information to pass between the inpatient and outpatient settings.

Early in the HIE rollout process we were forced to tackle the challenge of information overload, recognizing that bombarding physicians with every new piece of data would quickly become counterproductive. Data should enhance the provision of care, not become unwanted noise. Consequently, Banner developed procedures to make chart access and chart notifications two distinct functions.

The enterprise chart used by all of the ambulatory practices allows physician access to any patient record. Providers can actively search for and retrieve any information they need. However, separate processes now determine who receives notifications about specific pieces of information coming from the acute-care setting. Active notifications to physicians’ queues are customized.

For example, it was determined that primary care physicians want to be notified of emergency department (ED) and hospital admissions, and to get summary data from ED and hospital discharges. They do not want the daily CXR or labs of inpatients, but they do want labs and imaging results of studies ordered from their ambulatory practices. Surgeons, on the other hand, indicated the desire to receive op notes. They also need to be able to retrospectively import data from inpatient systems for patients first seen in the ED, but not yet registered in the ambulatory system.

By configuring automatic data exchange based on need – yet still providing data access to all – Banner hopes to reduce the “signal-to-noise ratio.” This will become increasingly important as more entities engage in HIE at broader levels. 

Driving Banner’s current ACO strategy is the concept of HIE at three distinct levels: private, community and state. (The fourth level – national – presumably will be obtained by exchange among the states.) The phased approach being used attempts to promote HIE adoption locally and ACO acceptance more globally, gradually acclimating users across the continuum of care.

As discussed, we began with the standardization of IT and clinical procedures across owned hospitals, then took the same process into the clinic environment. Plans call for the HIE initiative to be expanded next to non-employed affiliated physicians who admit to Banner (likely through the portal function of our HIE technology). Afterward, we will interface with other non-owned practices that have adopted the same EHR platform from NextGen Healthcare used at Banner-employed ambulatory practices, then to non-owned practices that use other EHR technology. Finally, the goal is to link to state HIEs in Arizona and Colorado.

Going forward, the key points of the strategy include:

• Initial rollout to employed physicians;

• The use of an enterprise chart within employed practices;

• Secondary rollout via portal technology to aligned physicians who admit to Banner Health facilities;

• Migration to HIE through interfaces directly into inpatient and outpatient EHR;

• Leveraging clinical content object workgroup (CCOW) standards for quick, context-sensitive access to disparate information systems;

• Interfaces with independent physicians on various EHR technology platforms; and

• Links from the Banner Health HIE to statewide HIEs.

To manage quality and costs, providers across disparate facilities and services will need to share utilization, outcomes and quality data in real time. Using this data to improve the efficiency and effectiveness of care will also require advanced analytics to continually develop and refine coordinated clinical protocols and point-of-care decision support. The success of any HIE or ACO endeavor, therefore, will depend on active physician participation.

As frontline decision makers, physicians are the primary end users of medical record systems. But they will only use them if they improve care and save time. Since the needs of physician users vary significantly by specialty, patient population and practice circumstances, it is essential to involve physicians in customizing HIE interface design to ensure usability.

On the other hand, data definitions and information sets must be standardized to support quality reporting, documentation requirements, research and population health tracking. So physicians must agree on common clinical procedures and documentation standards. To enable physicians to develop systems that are both flexible and structured enough to support all HIE needs, Banner relies on:

• Clinical informaticists: The ways in which IT solutions can benefit clinical care are not always obvious, and developing applications is technically challenging. Clinical informaticists have their feet in both the clinical and IT worlds, bridging the divide. Our team of clinical informaticists provides the vision to help physicians understand the potential of IT, as well as the translational skills required to help IT understand complex clinical problems.

• Leadership cultivation: In each clinical department and location, clinical leaders are identified to help promote application design and implementation. All physicians are encouraged to participate.

• Committee approach: When solutions cross clinical, process or IT boundaries – as they often do – specialty workgroups are convened to work through options.

• Project management resources: We use the tools and trained personnel for each rollout to ensure adherence to the schedule, good practices and communication.

Combined, all of these approaches have led to many practical solutions at Banner that make IT systems more usable. More importantly, however, physician engagement and flexible development processes create a framework for adapting to future needs.

The technology necessary to create the HIE of the future is decidedly not plug and play. But strategies can be used to standardize the management of HIE projects. By encouraging a process for innovation, healthcare organizations will be able to adapt to the continually evolving HIE and ACO environments.

Gregory J. Raglow, M.D., is the medical informatics director at Banner Health in Phoenix, Ariz.
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