ACOs, as they are called, exist at the center of a nationwide effort to improve healthcare quality and control costs. The groups pull together primary care physicians, specialists, hospitals and other providers with the goal of improving care coordination for a patient population. The focus is generally on chronically ill patients.
The number of ACOs has expanded rapidly since the Department of Health and Human Services established rules governing the organizations in October 2011. By January of this year, more than 100 Medicare-focused ACOs had been established, according to the Centers for Medicare and Medicaid Services (CMS), which administers the government's ACO initiative. Private-sector ACOs have also taken off in recent months. Leavitt Partners, a healthcare industry research firm in Salt Lake City, reported in February that 428 ACOs -- including government-backed and privately sponsored organizations -- exist in 49 states.
So what is the ACO IT angle? ACOs are effectively start-ups and often require a range of technology solutions. Consulting services play a role as well, as ACOs look for advice on how to organize participants along collaborative lines.
Jordan Battani, managing director of Computer Sciences Corp.'s Global Institute for Emerging Health Practices, said an ACO may have to orchestrate care providers as diverse as skilled nursing facilities and outpatient clinics.
"They all have to become part of this ... collaborative, coordinated model of care delivery," she said. "This requires a fundamental change in the way providers of care organize themselves," she said.
Structuring the ACO
ACOs may be structured along different lines. Typically, the first task at hand for a new group involves defining the organizational boundaries and relationships among entities. An ACO's structure will shape workflow patterns and technology decisions down the line.
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One distinction is between government and private-sector ACOs. Organizations that operate under CMS rules focus on improving the quality of care for Medicare patients. ACOs that succeed in boosting care and cutting costs -- through the elimination of duplicative services, for example -- can share in the resulting savings. In the private-sector scenario, providers may contract with a commercial health plan, agreeing to meet certain quality criteria. Shared savings or other financial incentives could be in the mix.
Alan Gilbert, managing partner for Health Catalyst Systems LLC, a healthcare consulting firm based in Haworth, N.J., said the ACOs he has worked with seem to have different ownership structures. Some, he noted, are wholly run by physicians, while others involve an alliance between physicians and a health system.
Health Catalyst Systems recently landed a project with an ACO in the latter category. Hackensack Alliance Accountable Care Organization, which consists of Hackensack University Medical Center and its affiliated physicians, selected Health Catalyst Systems to provide advisory consulting, as well as software and workflow algorithms for care coordination.
The company's ACO approach, dubbed Technology Enabled Active Management (TEAM) of Care, starts with the creation of a care team and then defines rules for various care activities. The rules are embedded in a care coordination workflow engine, which translates the rules into follow-up actions for members of the care team. A rule might prompt a doctor to schedule an HbA1c blood sugar test, for instance.
ACO IT layers
Once an ACO addresses the basic organizational issues, it can move on to IT. Electronic health records (EHRs) represent a foundational piece of ACO technology. EHRs provide the patient information ACOs need to coordinate care. The organizations launching now build upon an earlier federal initiative: CMS' “meaningful use” program. That program, which debuted in 2011 and runs through 2016, provides financial incentives to hospitals and doctors who adopt EHR technology.
'Meaningful use has really increased the availability of EHRs," Battani said. "If we had been trying to [create ACOs] five years ago, it would be a very different story."
With EHR systems maintaining patient records, the next step becomes sharing that data among coordinated care providers. That task calls for ACOs to pull together disparate systems, as participants tend to use EHR systems from different vendors.
"That is a huge problem for ACOs," said Nicole Bradberry, CEO of the recently formed Florida Association of ACOs (FLAACOs). "Picking the best integration partner or integration technology is one of the biggest problems to solve."
FLAACOs launched in April to promote collaboration among the state's ACOs. More than a dozen ACOs are currently operating in Florida, according to the organization.
Bradberry isn't alone in identifying the technology integration issue.
Every care community "is pretty much guaranteed to have electronic medical [record systems from multiple vendors]," added David Leach, vice president for Global Solution Consulting at Santa Clara, Calif.-based Orion Health Inc., which provides healthcare integration solutions.
Health information exchange (HIE) systems can play a pivotal role here, healthcare specialists say. HIE software translates among the incompatible EHR systems, providing bi-directional communication. An ACO needs to either acquire an HIE solution or build its own using an integration engine, Leach explained.
HIEs can help navigate mismatched EHRs, but they also serve as an ACO's central data source. An enterprise master patient index often features as a core HIE component, housing data on the patients treated within a given coordinated care community.
Health Catalyst Systems' care coordination solution platform, for example, offers a bi-directional HIE capability that includes a master patient index along with interface engines and semantic mapping. Leach also cited the master patient index as an HIE component.
"What we are seeing is organizations using HIE as a necessary building block of ACOs and for one primary reason: It has the data," Leach said.
Channel partners pursuing the HIE layer of ACO technology will find a shifting technology market. Health plans have been investing in HIE software in recent years, Battani noted. Medicity, for instance, is now a subsidiary of Aetna, while OptumInsight -- formerly Axolotl -- is associated with UnitedHealth Group.
The mode of HIE deployment has changed as well. The initial wave of HIE rollouts a decade ago often involved public exchanges spanning entire states or regions within states. HIEs supporting ACOs, however, tend to be local rather than regional, Battani explained.
ACO IT and analytics
Channel executives said most ACOs are still grappling with integration and HIE issues. Accordingly, that's where solution providers are seeing most of the customer demand for consulting and implementation services. But their current work could lead to an additional wave of projects. HIE systems, once in place, will pull in clinical data from a variety of sources. The next step: helping ACOs make the best use of that data.
"You have to be able to manipulate all the data and produce actionable information," Battani said. "What you don’t want to do is turn on this firehose and hit the ER doc with 10,000 disparate pieces of information."
Analytics and a big data strategy provide the tools ACOs need to offer actionable insights at the point of care, Battani noted.
Leach said analytics tools, at the basic level, will help ACOs identify at-risk patients. The next stage will involve using analytics to compare an individual's medical history with historical data across the patient population, he added. The analysis of population data will enable clinicians to observe patterns and make recommendations.
Orion Health provides some analytics capabilities, but it partners with Caradigm, a Microsoft and GE Healthcare company, for more advanced features. In March, the companies announced the integration of Orion's HIE system with Caradigm's analytics solution, the Caradigm Intelligence Platform.
Under the agreement, Orion Health also will serve as a referral partner for the Caradigm Intelligence Platform, while Caradigm will resell Orion Health HIE. Joint customers are expected to include ACOs.
Battani said the emergence of ACOs has become a focus of activity in the healthcare field.
"Almost everything that's going on in healthcare right now has something to do with this," she said.
This was first published in April 2013