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CMIO breaks down HIT challenges for provider ACO participation

Our latest Q & A features Northshore University HealthSystem CMIO Arnold Wagner, M.D., who explains the HIT aspects of ACO participation.

Since 1995, Northshore University HealthSystem CMIO Arnold Wagner, M.D., has led the charge for the implementation of the country's first patient-focused, community-based longitudinal health record at an integrated healthcare system.

As such, he knows what it takes to get providers collecting the right patient data -- and the IT systems it takes to concatenate that data in a usable form. In other words, he's already developed the workflows that thousands of health care informaticists and CIOs will need to do for accountable care organization (ACO) participation as well as joining other quality- and value-driven payment programs from private payers. reporter Don Fluckinger sat down with Wagner to discuss this notion of ACOs and the back-end IT systems that support the reporting and analytics participation requires.

What is the biggest challenge for ACO participation?

Arnold Wagner: Operationally, having enough consistent, timely, accurate information to support timely analysis and decision support; having an outbound education tool to disseminate knowledge and policies; and having truly interoperable data and workflows.

Politically, the challenges include having disparate providers and sites of care begin to act with community benefit in focus, not parochial benefit in focus -- avoidance of pain is not as strong a motivator as aspiration for gain.

How does a CMIO go about solving those challenges?

Wagner: Sell the vision of "patient-focused, community-based, longitudinal health record."

Run it on a single platform, populate it with information that is current, comprehensive, accurate and timely. Foster communication that is immediate and transparent, and participation within a center of excellence. Then pressure patients for participation, and leverage the economic support to the extent allowed by regulatory bodies. Extend it to community practices. Walk the talk of being clinically focused.

Optimize clinical workflows by taking as many steps out as you can: Strive for the goals of single data capture, broad sharing and re-use. Facilitate feedback to support or modify performance and care. Finally, keep it running with infrastructure redundancy that maintains availability of health data.

Why will the ACO idea succeed or ultimately fail in your opinion?

Wagner: Economics vs. expectations.

So what do you think will be the make-or-break criteria?

Wagner: You can't manage what you don't know. A common database that is capable of real-time total knowledge use is needed for optimal, safe clinical care. A comprehensive common database is needed for population awareness, syndromic surveillance, prospective physician education and patient management.

Read more on the IT of ACO participation

ACOs will require complex clinical decision support.

And don't forget the data analytics component.

See the latest ACO discussions on our HIT Exchange health care CIO community site.

Some hard questions will have to be answered: Is it a sustainable economic model to incentivize individuals to pursue a medical career and spur communities and organizations to support facilities and programs to their level of need and aspiration? Is there appetite and understanding within the larger community for acceptance of evidence-based, economically aware, hard decisions?

Is there incentive or appetite within the vendor community for true data transparency and workflow transparency? Merely providing the ability to look some fact up is an order of magnitude easier than representing knowledge (facts and reference) at the point of need in the format that it is needed along with the opportunity to act.

Individuals frequently use the banking analogy: If I can get money anywhere in the world from my bank account, why can't I access my entire medical record and use it in the same way? The bank model only works looking at your bank. In the medical world you have multiple "banks": physicians, hospitals, independent labs, radiology services, pharmacies, physical therapists, etc. -- and they all speak different languages. Each of these medical "banks" has optimized their relationship with you in a way that meets the unique needs of your particular focus and transaction.

We see Pioneer ACOs investing heavily in IT infrastructure to connect all the patient data dots. Even if the next payment model in US healthcare isn't exactly the ACO, that infrastructure should pay off, right?

Wagner: Maybe. Depends on how you define "pay off." Clearly we need to be more careful and efficient in spending our health care dollars. Some of that efficiency can be wrought from low-hanging fruit of reduction of duplication. It is a current tenet of belief that significant benefit can also be wrought through "preventive care."

Preventive care should be thought of in two categories:

  • Healthy lifestyle. Lose weight, exercise, eat right, don't smoke, don't expose yourself to hazardous environments or behaviors.
  • Early diagnosis. The best lifestyles will not prevent disease, so it is better to detect disease early, when the course may be relatively easily modified.

Optimize clinical workflows by taking as many steps out as you can: Strive for the goals of single data capture, broad sharing and re-use. 

Northshore University HealthSystem CMIO Arnold Wagner, M.D.

Good, safe, efficient care depends on access to complete information, so a connected health community is an essential component. But will the connectivity pay for itself and result in a net total national expense on health care, or is it simply shifting dollars from actual care to infrastructure support? Again a "lookup utility" that allows clinicians to find information is an electronic file box, it is not an integrated workflow engine. The lookup engine supports consistent formatting, consistent location to seek information, legibility, but it still requires me to seek the information. And, it has to be paid for.

An entity that is at risk for healthcare expenditure needs data to be most efficient. So the infrastructure to support the risk management needs to be baked into the cost of care. The ACO (or any entity at risk) becomes the insurance company. For insurance to work there needs to be diffusion of risk, universal participation. That element of evolution was just defeated by the U.S. Supreme Court.

You're a pioneer in developing one of the country's first longitudinal health records for a patient population. Explain what that is and how it differs from an EHR a practice might be setting up in their offices.

Wagner: Big data. The essence is that it's not just their offices. It is a "patient-focused, community-based, longitudinal health record." It's a cloud of knowledge that follows the patient wherever she may seek care. It's a single repository of the patient's experiences. It is a virtual single medical group, bound together by the record. The clinical data is wide open to all appropriate clinicians, but the financials are siloed. The patients benefit from all caregivers being aware; the physicians benefit from comprehensive, timely, consistent information; the enterprise benefits from a comprehensive patient record when admissions are needed.

The enterprise EHR supports a data warehouse, which allows us to have a global view of the patient, with inputs from multiple disparate encounters. This supports diagnosing otherwise undetected disease states by putting the separate pieces together. A larger database allows easy physician performance and behavior analysis. Simple awareness of how I perform relative to peers can incite improvement.

Big data analysis allows better understanding of "normal" and variation from normal.

Patient awareness of "systemness" drives patient loyalty and satisfaction. Patients previously had a general sense of where their physician may have hospital privileges, but in the current age of multi-provider care, patients are consciously aware of "systemness" and how their physicians and hospitals "play well together." They have an interest in an integrated coherent record. In integrated system, I can be calling a patient with diagnostic imaging results, seen in my EMR in-basket, as she is driving home. Instant communication and gratification is one of the drivers of modern expectation.

What's the key to creating a longitudinal health record that succeeds?

Wagner: The strategic keys: vision, focus, commitment, resources. Success is not a "while you are at it" project.

Operational keys:

  • Availability, speed, comprehensive information, current information, ease of communication, anticipatory workflows, patient participation.
  • Broad/universal provider participation. (Provider in the broad sense: hospital, lab, rad, physicians, ancillaries.) That's what makes the record comprehensive.
  • The EMR is the "physician cockpit" and the "patient window to my medical world."

In the current health IT universe this means a single platform enterprise-grade EMR with broad extension to the community. The coming world, I believe, will see caregivers aggregating around their knowledge platform for patient benefit and their survival.

What advice would you give to your peers who are just setting up EHR systems with an eye toward the longitudinal health record?

Wagner: This is not about EMRs and neat records, it's about transforming care delivery, communication, safety, efficiency (more work, but a much better product). The record is now a part of the patient; it is not mine, and it needs to be respected and cared for just like the patient.

Extend, extend, extend as fast and as far as you can. Build community. Your ultimate strength and value will directly relate to becoming the source of truth about your patient community.

Health information exchanges will offer the ability to view external data, but the strength of workflow supporting real-time, comprehensive knowledge is an extremely powerful clinical tool. It makes physician care better, safer. It makes care improvement and practice improvement possible through big data.

Avoid the two worst phrases in IT: "It's just an interface," and when you want information "you just go to …" The HIT opportunity is to put that data in your face when and where you need it.

Words to live by, uttered by renowned Chicago architect Daniel Burnham, but the idea certainly applies to the coming world of health IT: "Make no little plans; they have no magic to stir men's blood … and probably themselves will not be realized. Make big plans, aim high in hope and work, remembering that a noble, logical diagram once recorded will never die, but long after we are gone will be a living thing, asserting itself with ever-growing insistency."

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