Accountable care organizations rely on sophisticated data analytics to help meet quality and cost targets. An executive from Boston Children’s Hospital’s ACO recently described the long and winding road his organization has taken to support that work.
Speaking to the Harvard Clinical Informatics Lecture Series on Feb. 2, Michael A. Lee, M.D., M.B.A., executive director and medical director in the Department of Accountable Care and Clinical Integration at Boston Children’s Hospital, said in hindsight perhaps the ACO didn’t do quite enough needs assessment work before they started implementing data warehouse and analytics tools.
To move forward in the value-based care world, you need to think about what you are trying to accomplish first, said Lee, who previously served as senior director of clinical informatics at Atrius Health, the largest independent physician-led healthcare organization in the Northeast. “Boston Children’s didn't think deeply enough about how the data and information was going to make changes we were interested in making. You need to do a deeper needs assessment, identify the problem you are trying to solve, and articulate it.”
For ACOs, he added, sometimes it is still not immediately clear what the goal is. Yes, they want to hold the rate of expense to a lower level, but it is not always clear what they want to deliver in terms of outcomes. If you are trying to solve cost and quality at the same time, there are a big basket of choices, he said. You could look at reducing high-volume unnecessary services or high-cost, low-volume services. You also have to ask: What can be measured? What can be compared? What to make better for whose benefit? For payers? Doctors? Patients?
Sometimes, Lee said, you could get caught measuring things just because you can measure them. For instance, in pediatrics you could easily measure well visits and vaccination rates, but with rates so high across most health systems in Massachusetts, it is difficult to make that a differentiating characteristic.
The Boston Children’s ACO is involved in a Medicaid ACO with the Commonwealth and an alternative quality contract with Blue Cross Blue Shield of Massachusetts.
Setting up the data infrastructure before the ACO’s launch had some ups and downs, Lee said. The work began before he moved over from Atrius. Boston Children’s decided to work with Cerner’s new HealtheIntent data warehouse platform. The plan was to bring in all the claims data and clinical data into that warehouse to blend for analytics purposes. “There should have been more talk about the purpose. We didn’t have good decision making around that,” Lee said. “It was a brand new tool, so using it to do something this complicated and new was not the best idea. There was a plan for interfaces, but not how the migration and data validation would work. It was not very clear how many pieces were going to plug in together.”
One challenge was that different teams were adopting different platforms. The Pediatric Physicians’ Organization at Boston Children’s Hospital (PPOC) made up of more than 400 physicians, nurse practitioners and physician assistants, was in the process of rolling out Epic, and it made more sense for them to use Epic’s Healthy Planet data warehouse. A care management team was using an Athena warehouse for tracking activities. “There was a sequence of not great decisions,” Lee said. “After six months, we were really struggling to move it forward.”
Lee said they really needed to rethink the entire idea, but the problem was that the ACO was set to launch. “Cerner was invested in making this work, so we decided to push forward with claims only in the warehouse before doing any further investment.”
The good news, he said, is that the ACO is functioning well. They are getting claims data from multiple payers, and the reporting is timely and accurate. The team they have put together has worked out well. The ACO has 22 quality measures, and Lee said some of them demonstrate how access to services for patients, such as behavioral health, has improved throughout the ACO. The analytics tools are allowing them to track sub-populations and do a better job of understanding them, and clinical teams have been deeply involved in deciding what to measure.
“We have gotten to data stability,” Lee said. “Now we have to step back and say OK, where do we want to go from here?” He reiterated his opinion that a strong needs assessment should be done upfront before investing in the data operating system assets. “Installing the thing without thinking about how to use it and resource it longer term is not the ideal way to do it,” he said. “You shoot yourself in the foot if you don’t do the needs assessment.”
