The West Orange-based Barnabas Health is the largest integrated health system in New Jersey, encompassing seven acute-care hospitals, two children’s hospitals, a freestanding behavioral health center, ambulatory care centers, geriatric centers, the state’s largest behavioral health network, and comprehensive homecare and hospice programs. In May, it signed a definitive agreement for Jersey City Medical Center in Jersey City to become a member of the health system, with completion of the transaction scheduled for this fall.
Barnabas Health has created two accountable care organizations (ACOs) and three ACO programs. Barnabas Health ACO North encompasses three acute-care hospitals and 400 physician partners, and currently serves about 10,000 Medicare beneficiary lives. The Central New Jersey ACO consists of three Barnabas Health hospitals, as well as the participation of CentraState medical Center, a non-Barnabas hospital. That ACO encompasses 200 doctors and serves about 20,000 Medicare lives. Both Barnabas Health ACO North and Central New Jersey ACO are Medicare Shared Savings Program (MSSP) ACOs (with the program being sponsored by the federal Centers for Medicare & Medicaid Services, or CMS), with Barnabas Health ACO North joining the MSSP in July 2012 and Central New Jersey ACO joining in January 2013. Barnabas Health also recently announced a relationship with Horizon Blue Cross and Blue Shield of New Jersey to create Medicare Advantage program together.
What’s more, Barnabas Health ACO North’s collaboration in NJ-HITEC, the state’s regional extension center and a statewide health information exchange (HIE), has been so successful that it was cited by National Coordinator for Health IT Farzad Mostashari, M.D., in a statement he gave on July 17 to the U.S. Senate Finance Committee. The Piscataway, N.J.-based IGI Health has been providing software platforms for both the ACO and the REC. Recently, Anthony Slonim, M.D., vice president and chief medical officer at Barnabas Health, spoke with HCI Editor-in-Chief Mark Hagland regarding all these initiatives and the broad strategies and the implications for U.S. healthcare of these types of collaborations. Below are excerpts from that interview.
I understand that you’ve been exceptionally involved in IT implementations and initiatives as a CMO.
Yes; I’ve done 16 EHR [electronic health record] implementations in my career: eight each with Cerner and Epic [the Kansas City-based Cerner Corporation and the Verona, Wis.-based Epic Systems Corporation].
I did the design-and-build for Cerner for Children’s Hospital Medical Center, Washington, D.C., when I was there [2003-2005, 18-month implementation]; I then supervised the design-and-build at Carilion Clinic in Roanoke, doing an eight-hospital install using Epic, when I was CQO [chief quality officer] there in 2007-2009. And here, we’ve been on a journey for about two years, and I’ve been here about two-and-a-half years altogether; and we’ve just implemented our last ED. So we’re now live in six acute-care hospitals and a behavioral health center—EMR [electronic medical record], CPOE [computerized physician order entry], and EDs [emergency departments], using Cerner. And we’re also on a journey to use Cerner ambulatory among our employed physician practices. And at Barnabas Health, the CIO actually reports to me.
How many people does your CIO have in IT?
The IT division is system-wide, and we have over 200 employees. It’s the one department that’s system-wide, across all seven hospitals and the behavioral hospital.
What have been the biggest strategic learnings overall, around ACO development, to date?
You experience several key learnings as you start up an ACO. And I’ve often been quoted as saying, when you’ve seen one ACO, you’ve seen one ACO; they’re all structurally different. In the first year, we spent time hiring people, setting up committee structures, creating data linkages, and to make sure we had the appropriate structure for analytics. And ultimately, this leads into the IT discussion, because we decided that rather than building new infrastructures, we would find partners. So we decided to work with IGI to help us with connectivity, analytics, and other aspects. It’s a consulting company that works with us in depth, to help us advance our infrastructure, connectivity, and data warehouse structure. They’re a partner with us, as are NJ-HITEC, the HIE, and Advantis International, the IT staffing company, which helps to facilitate data analytics and integrity for multiple ACOs.
Once you get up and running, what are the biggest challenges in ACO operations in the first year or two?
Putting the infrastructure together, making sure we had seamless connectivity and communications, and making sure we had a portal infrastructure to make sure we could allow the providers to communicate with one another. And We had a major deliverable for CMS, to make sure we were submitting our performance reports on time.
Have you had any challenges around supporting quality measure reporting?
There are 33 quality measures in the MSSP program. They fall into three major buckets: clinical, patient satisfaction, and utilization measures; and CMS puts them into four different domains. And those 33 quality measures are objective measures of quality. They tend to focus as diabetes, CAD, and CHF. And the data bundles that CMS prescribes are actually pretty clear and well-represented measures of those disease states. They’re tried, true and tested measures.
Have there been any biggest challenges working with CMS?
I hesitate to be too critical of CMS for a variety of reasons, and one is that everybody in the program is learning, which is good. It’s all about everybody learning together; and CMS hasn’t actually done a program like this before. And they’re bringing people in from around the country, and it’s about learning, not criticisms.
What have the main strategic IT challenges been?
Well, I think the IT challenges are made more difficult if you go about building the IT infrastructure yourself. We decided we would partner with a consulting team to get the show up and running. While we were focused on getting the ACO put together, they were focused on putting together the infrastructure and analytics elements.
What are other ACO leaders saying to you, and what are you saying to them, at this stage?
I was actually interviewed as part of a group of five ACO leaders, and there were amazing similarities. We all recognize how important data is to advancing the quality of care. And so ensuring that your IT infrastructures and analytics are as robust as possible, is incredibly important, because you need to be able to improve the care that those measures represent.
Do you think some of the trade press coverage has given an impression that is darker than the reality?
The coverage is valuable, because we’re all learning together. And because of that, you get disparate information, right? I try to be as concrete and clear as possible. And no one’s ever done this before. If healthcare had already been fixed, and it was running like a smooth engine, we wouldn’t even be dealing with these challenges. But we are dealing with them, because healthcare is largely inefficient, and we have the opportunity to improve value through improving care quality at the same or lower costs.
What do you see happening for your own two ACOs and ACOs across the country, in the next two years?
We’re all going to get a lot better. We have never as an industry had our hands around data that rates the performance on specific measures outside the hospital. This is revolutionary. And if you don’t have the data, you can’t get your arms around that challenge. And we’re getting our arms around the data. So where will we be? And critics have suggested that ACOs will be gone in two years when the program is retired. But the value proposition is here to say. We have to figure out how to get rid of the estimated one-third of the cost of healthcare that is wasteful. And so the conversation will persist long after the term “ACO” is gone.
I got a call from someone not long ago who’s a graduate student and who said to me, “Dr. Slonim, I’ve decided that my career in healthcare is in ACOs.” And I said, “Well, you may have a very short career, but on the other hand, if you focus on how we improve quality, improve patient satisfaction, and lower costs, you’ll have a very long career.”
And to the extent that CMS is driving us to think about these issues, via the ACA [Affordable Care Act] legislation—to the extent that healthcare reform is driving us to think creatively about solutions and to be able to innovate—that’s good for healthcare. And while the CMS MSSP program is just one program, we now have private payers, like Horizon, coming to us, to do the same thing. And it won’t be long before the states, through Medicaid, and the health insurance exchanges, come to us as well. And they’ll continually up the ante in terms of the deliverables. But CMS started the conversation; and congratulations to them to advance the conversation on a national level, and we all have to continue it.
And even at the local, Region 2, level of CMS, I give great credit to our partners. And I’ve been to the White House. And I think people are continuing to reach out to us.
And this morning, we just kicked off our optimization initiative, to take a clinical lens to how the information system works and meets the needs of providers. And rather than look at this through an informatics lens, I want to look at this through a clinical lens.
