MADSION, Wis., Jan. 31, 2013 -- Symphony Corp., a global healthcare technology solutions provider, announced David E. Thomas has joined the company as a Regional Sales Manager. Thomas, who will be based in the Chicago, Ill. area, will be responsible for introducing Symphony's Epic Clarity reporting services to healthcare service providers.

"We're thrilled to welcome David onboard our fast growing team," said Nick Willocks, president of Madison, Wisconsin-based Symphony Corp. "David brings to Symphony vast experience in selling Enterprise Resource Planning software, even having worked for some of our ERP vendors. His proven track record will assist us in expanding our network and building out partnerships with healthcare providers, utilizing his extensive expertise in Lawson and SAP."

Thomas has nearly 20 years of experience in healthcare IT software solutions with specific experience in Enterprise Resource Planning (ERP) software. He previously worked for Lawson Software, a New York City-based leading ERP vendor; Blue Horseshoe Solutions, a Carmel, Indiana-based solution services company; and intelligence, a Cincinnati, Ohio-based global reseller of SAP Software and hosting/managed services.

"Symphony's Epic Clarity reporting expertise encompasses strategy, planning and process improvement with Epic Clarity and Reporting workbench," said Thomas. "I am excited to offer this service to my existing contacts, offering Chicago-area clients Symphony's report development, clinical systems integration and data management solutions to deliver reporting solution in less time and with less cost."

To date, 32 organizations across the country are participating in the Pioneer ACO initiative, hoping to inspire others in their regions to follow suit. As the benefits of adopting this model become clear, more organizations are looking to explore the possibility of becoming an ACO.

Ron Parton, MD, chief medial officer at health IT firm Symphony Corporation, outlines seven critical success factors for ACOs.

1. Align the payment model with value. The key for organizations to be successful in these types of new payment arrangements, said Parton, is to make sure they have the payment arrangements in place as they change their care delivery models. "There are organizations and integrated systems around the country that have introduced their quality improvement programs before entering into a shared risk arrangements, and [they] have improved quality significantly but have lost revenue because they reduced fee for service business," he said. "So one of the keys is to try to make sure you're matching your payment model with your quality improvement efforts so you don't get ahead of yourself." And once you've created that type of payment model, Parton added – whether it's participating in a Medicare shared risk arrangement, or a local or national insurance company that's creating a pay-for-performance or a shared risk opportunity – it becomes a question of investing in the right type of infrastructure.

2. Pay attention to leadership and cultural change. According to Parton, one of the most pressing things to understand when changing payment models is that specialty physicians, in particular, may struggle with understand the importance of these new arrangements, since most have depended on fee-for-service to be successful through their careers. "So, it's important to pick leaders who are forward-thinking and who will support the new care payment arrangements," said Parton. These selected individuals can help lead initiatives across the medical staff. "Once you get some of the medical staff bought in, it's important to invest in infrastructure that helps them be successful in the new model," he said.

[See also: ACOs dominate early discussion at MGMA conference.]

3. Hire experienced health professionals, especially nurses and health coaches. Part of driving cultural change, said Parton, is to hire staff to help make these new initiatives successful. "One of the key factors of all this work is to identify complex patients who have difficulty navigating the system, managing their own illness, taking medications, etc.," he said. "The professionals who have skill sets to change that behavior may be different than what current integrated systems have hired." Identifying nurses who understand how to implement specific techniques and help patient manage their illness can drive the transition more quickly, said Parton, therefore making it essential to have these types of staff members on board.

4. Take the time to gain buy in from the primary care practitioners and their staff. Naturally, there will be practices that are resistant to change, said Parton, so make sure you touch base with every practice and have a contact and leader in each to help educate and lead their group. "This is extremely important, otherwise, people will give lip service but they won't change their workflow of how they're managing their practice day to day," he said. He added that a lot of the work doesn't need to be done by physicians, but by associated in their offices, like nurses, medical assistants, nutritionists, etc. "Getting that buy-in across the entire staff of a practice is important," he said. "It's not just the practitioners." Keep in mind the role EHRs will play in the transition, Patron added, especially when it comes to adding more work to learning the new IT system. "Doing this work for an ACO is additional stress," he said. "So helping them understand some techniques, some new tools they can use to improve their work is part of the issue."

[See also: ACO program is asking too much, says expert.]

5. Develop the data model, IT infrastructure, and tools to support reporting and analytics. One key piece for larger organizations, said Parton, is getting all organizations involved in the transition on the same page. "There are multiple organizations involved, and they come together to do the shares risk arrangement," he said. "So they may be on multiple systems and multiple data sources, and one of the challenges upfront is integrating and taking data from all those sources into one common data warehouse." The first step, he added, is to identify who's participating in the ACO and what the differences are in their data infrastructures. The next step is to create interfaces with each separate data source to do mapping. "That's where the data model comes in," he said. "You need to make sure you understand the differences in data from one entity to the next … all that detail is extremely important." The last step, said Parton, is pulling the data and integrating it into a common platform, "so if you invest in that, you have the data to do any of the programs, projects, or measurements, and it makes your life so much easier if you do all that upfront."

6. Invest in a population health and care management system, and integrate with the EHR. A population care management system allows you to take data from all your sources and use it specifically to track and manage subpopulations, said Parton. "You want to target and allow care teams to do follow-up work with care plans, " he said. "The population care management system can be the common care plan platform that allows professionals to track and manage patients across the system... care is coordinated in a way that helps people stay out of the ER and out of the hospital." In turn, the system takes nightly feed of EHR data and makes it available to care teams, allowing them to determine gaps in care by seeing the care across an entire population. "Whether they're following evidence-based guidelines and are looking for patterns of someone not taking medication, or they have multiple doctors managing care and it's uncoordinated, they can look for that pattern," said Parton. "They can target the right patient and give them the care they need."

7. Match the organizational readiness for change. "All the things an ACO needs to do simultaneously, it's a lot of work and a lot of change for an organization," said Parton. "It's important for the organization to continuously monitor how well these initiatives are going on a daily or weekly basis and make sure you're not getting ahead of yourself." Constant communication and listening, Parton continued, in terms of feedback from physicians is key. "At some point, you may find you have to step on the brakes for a bit because you have to wait for your IT team to catch up," he said. "Or, from a payment model perspective, you have the model in place and need to accelerate those results-oriented projects because you need results from the bottom line sooner. It's about stepping on the brake or the gas to make sure things are moving."

New population health tools needed to effectively manage ACOs.

The Centers for Medicare & Medicaid Services' (CMS) final rule on accountable care organizations (ACOs) includes 33 measures on overall performance while allowing providers options on shared savings. While the new ACO rule is likely to persuade payers and providers to provide better quality at a lesser cost, it now draws focus on a greater need for new population health information technology to support ACOs.

Current reporting technology and electronic health records (EHRs) may be able to provide basic reporting on the measures, but they are woefully inadequate at meeting the ACO requirements for improving care, enhancing the patient experience and reducing costs. Health information exchanges may provide continuity of care records for patients at the point of care, but they do not integrate care plans, document interventions, support task management or measure outcomes. New population and care management systems will be required to support primary care medical home models, care coordination, case management and transitions of care. Advanced healthcare delivery will require the adoption of new information systems and tools that:

• Provide rapid, flexible and continuous performance reporting;
• Promote the proactive identification and management of the "highest risk" patients;
• Accurately attribute patients to physicians and care teams;
• Allow care teams to coordinate care across the entire continuum and systematically manage multiple chronic illnesses through use of a common care plan – clinical integration;
• Integrate information and workflows across EHRs, care teams, providers, community resources and health information exchanges (HIEs);
• Support real-time decision making and population surveillance using evidence-based guidelines;
• Engage, educate and support patients in self-care, prescription drug adherence, lifestyle improvement and prevention; and
• Aggregate and manage data from multiple disparate data sources (clinical, administrative and financial) with reliable master patient index functionality.

Data warehouse/data repository

It is important to be able to integrate multiple data sources, including ambulatory and inpatient EHRs, labs, scheduling, billing, health information exchanges (HIEs), insurance claims, remote monitoring, patient self-reports, research, demographic, administrative and financial data.

In general, the data warehouses that are included with EHRs are not designed for integrating financial, clinical, research and administrative data from multiple external sources or for use in tracking healthcare interventions and outcomes for populations. To improve and report on performance, an ACO will need to create a data warehouse and/or repository to store all available data on its patients and services and make this data available across the enterprise to support population and care management initiatives.

Population health and care management system

A population health and care management system should include an enterprise multi-disease registry with measures and reporting; workflow support and tools for case management and health coaching; care team performance tracking with an embedded rules engine to support follow-up tasks and reminders; and creation and sharing of care plans that include longitudinal care views of goals and progress.

Chronic illness registry tools typically have been developed for single diseases and have produced lists of patients that need follow up or have “care gaps,” but do not include case management tools or health coaching functionality to manage and/or document the work in coordinating care and assisting patients with their illnesses. These tools help facilitate identification and can report the results, but they do not manage the workflow across multiple diseases or support case management/health coaching. New population health and care management systems are now available that are multi-disease and can help care teams with role-based task management, care coordination, prescription drug adherence, patient letters and reminders, lifestyle tracking to goals and comprehensive clinical and financial performance reporting. They are designed to be flexible and accommodate different workflows across the care teams and also allow for ongoing changes in measures, definitions and guidelines as required.

Population surveillance rules engine

Staff should be able to monitor care processes and outcomes using evidence-based guidelines, with links to both a population and care management system and the EHR.

Most EHRs will facilitate reminders that “pop up” during a patient encounter to flag the need for routine preventive screenings, immunizations, lab tests and care gaps, but they are not very flexible and do not connect to a follow-up tracking system that facilitates role-based workflow for the care team. Since EHRs are visit based, they generally don’t trigger actions between encounters, don’t allow flexible workflows for follow up across the care teams and don’t document interventions or communication attempts. Evidence-based rules engines that exist outside of the EHR can support population management by the care teams for actions that are triggered, often avoiding the expense of a face-to-face visit with the practitioner. New population health and care management systems will incorporate evidence-based rules engines for population surveillance and support care teams in closing the care gaps.

Clinical integration of systems

Integrating population health IT with EHR functionality and workflow is a must.

The complete set of information about each patient must still be stored in the EHR to support optimal patient care. This requires that new information generated in a population and care management system be fed back to the EHR, so it is available at the point of care for decision making and follow up. The workflow between the EHR and the population and care management system must be optimally integrated to help assure efficiency and access to the data. Over time, some of the population health functionality that isn’t available now may be incorporated in the EHR itself. However, EHRs are usually structured around encounters rather than populations, care teams, or non-encounter-based workflows. This may ultimately limit the capacity of most current EHRs to incorporate population health IT functionality. Certification Commission for Healthcare Information Technology (CCHIT) certification ensures that the EHRs are positioned to exchange patient information bi-directionally. Little attention has been given to developing functional integration of workflows across systems, access to computer physician order entry (CPOE) for population management or making this integration commonplace.

Analytic tools

Analytics tools should focus on predictive modeling, episode grouping, severity and case mix adjustments.

Predictive modeling tools support proactive identification and stratification of the highest-risk patients for potential referral to complex case management. A parallel methodology is also needed to measure cost and utilization with case mix adjustment, typically through episode groupers.

Remote monitoring technologies

Home monitoring must interface with care management and EHRs.

High-risk patients with certain chronic illnesses such as congestive heart failure, diabetes, hypertension and chronic obstructive pulmonary disease may benefit from utilizing home-monitoring devices that allow them to track their own illnesses and work interactively with a case manager and/or health coach who can also follow and track their outcomes in real time. This information can be sent back to both the population and care management systems and the EHRs.

Patient and family engagement technologies

Patient and family engagement technologies include Web-based portals linked to personal health records; lifestyle tracking tools; handheld technologies for education, tracking, reminders and interactive learning; Web-video technologies for virtual provider visits, health coaching and case management; and interactive assessments, questionnaires and connectivity to measure patient outcomes and provide feedback on patient experience.

Patients are now being provided access to their own medical record information and encouraged to learn more about and manage their own health risk factors and chronic illnesses. Mobile and tablet technologies, Web-based patient portals and Web-video technologies are allowing patients to have better access to their care teams, medical knowledge and tools that help them to improve their lifestyles and achieve better results in managing their illnesses. These technologies can be linked to both their population and care management tools and their EHRs. Patient experience questionnaires, interactive assessments for depression screening, assessment of activities of daily living, pain management follow up, etc., can be administered using email, patient portals and/or handheld technologies.

Population health information technology

Population health information technology is complex to implement but critical for ACO performance.

Population Health IT for ACOs:  A Patchwork Quilt

By Ron Parton, MD, MPH

The new ACO rule has big implications for information technology. In the final rule on accountable care organizations (ACOs), CMS has included 33 measures that report overall performance while allowing providers options to share in any savings. Because the new ACO rule will no doubt steer payors and providers to improve quality and reduce costs, the need for population health information technology to support ACOs has dramatically increased.

Current reporting technology and electronic health records (EHRs) may be able to provide basic reporting on the measures, but they are woefully inadequate at meeting the ACO requirements for improving care, enhancing the patient experience and reducing costs. New population and care management systems will be required to support primary care medical home models, care coordination, case management, and transitions of care. Advanced health care delivery will require the adoption of new information systems and tools that:

• Provide rapid, flexible and continuous performance reporting
• Promote the proactive identification and management of the “highest risk” patients
• Accurately attribute patients to physicians and care teams
• Allow care teams to coordinate care across the entire continuum and systematically manage multiple chronic illnesses
• Integrate information and work flows across population & care management systems, EHRs, care teams, providers, community resources, and health information exchanges (HIEs)
• Support “real time” decision making and population surveillance using evidence-based guidelines
• Engage, educate and support patients in self-care, prescription drug adherence, lifestyle improvement and prevention
• Aggregate and manage data from multiple disparate data sources (clinical, administrative & financial) with a reliable master patient index functionality

An array of technologies and information tools to piece together: A patchwork quilt

Integrated delivery systems such as Kaiser Permanente, Geisinger and Group Health Cooperative have incorporated population health information technologies to varying degrees to improve quality, reduce costs and enhance patient experience. These leading organizations found their EHRs insufficient for population health management. Since their electronic health records lacked this functionality, they ultimately developed and/or bought, and then pieced together their data, systems, tools and reports. In fact, these systems have spent a considerable amount of time and money on creating these tools themselves. These collections of support tools, registries, and systems are far from perfect, but have allowed these organizations to accomplish impressive results that have set them apart as national leaders in managing quality and cost. Organizations of physicians and hospitals that are striving to create ACOs can build on the experience of these integrated systems to improve their performance under healthcare reform. Building on top of an EHR, the following components create a population health IT system:

Data warehouse/data repository – Integrating multiple data sources including ambulatory and inpatient EHRs, labs, scheduling, billing, health information exchanges (HIEs), insurance claims, remote monitoring, patient self-reports, research, demographic, administrative and financial data

In general, the data warehouses that are included with EHRs are not designed for integrating financial, clinical, research and administrative data from multiple external sources or for use in tracking health care interventions and outcomes for populations. To improve and report on performance, an ACO will need to create a data warehouse and/or repository to store all available data on its patients and services and make these data available across the enterprise to support the population and care management initiatives.

Population health and care management system – Including an enterprise multi-disease registry with measures and reporting; work flow support & tools for case management and health coaching; care team performance tracking with an embedded rules engines to support follow-up tasks and reminders; creation and sharing of care plans that include longitudinal care views of goals and progress

Chronic illness registry tools typically have been developed for single diseases and have produced lists of patients that need follow-up or have “care gaps”, but do not include case management tools or health coaching functionality to manage and/or document the work in coordinating care and assisting patients with their illnesses. These tools help to facilitate identification and can report the results, but they do not manage the workflow across multiple diseases or support case management/health-coaching. New population health and care management systems are now available that are multi-disease and can help care teams with role-based task management, care coordination, prescription drug adherence, patient letters and reminders, life style tracking to goals, and comprehensive clinical and financial performance reporting. These population health and care management systems are complementary to and can integrate with EHRs. They are designed to be flexible and accommodate different work flows across the care teams and also allow for the inevitable changes in measures, definitions and guidelines that will occur from time to time with medical advances.

Population surveillance rules engine – To monitor care process and outcomes using evidence-based guidelines, with links to both a population and care management system and the EHR
Most EHRs will facilitate reminders that “pop up” during a patient encounter to flag the need for routine preventive screenings, immunizations, lab tests and care gaps, but they are not very flexible and do not connect to a follow-up tracking system that facilitates role-based work flow for the care team. Since EHRs are visit-based, they generally don’t trigger actions between encounters, don’t allow flexible workflows for follow-up across the care teams, and don’t document interventions or communication attempts. Evidence-based rules engines that exist outside of the EHR can support population management by the care teams for actions that are triggered, often avoiding the expense of a face-to-face visit with the practitioner. There are population health and care management systems that incorporate evidence-based rules engines for population surveillance and support care teams in closing the care gaps that are identified.

Clinical integration of systems - Integrates population health IT with EHR functionality and work flow

While much of the routine population health and care management work can occur outside of the typical physician encounter, freeing up physicians to concentrate on the more urgent issues, difficult medical problems and complex patients, the complete set of information about each patient must still be stored in the EHR. This requires that new information generated in a population and care managements system be fed back to the EHR, so it is available at the point of care for decision-making and follow-up. In addition, there may be actions that are triggered in the population and care management system such as scheduling a lab appointment, a change in a prescription drug and/or a follow-up physician appointment that can be executed in the EHR. The work flow between the EHR and the population and care management system must be optimally integrated to help assure efficiency and access to the data. Over time, some of the population health functionality that isn’t available now may be incorporated in the EHR itself. However, EHRs are usually structured around encounters rather than populations, care teams, or non-encounter-based workflows. This may ultimately limit the capacity of most current EHRs to incorporate population health IT functionality.

Advanced reporting - Tracking financial, administrative and clinical performance

Decision making to support improved quality and reduced cost requires a full set of internal financial, administrative and clinical performance reports that measure their own performance against benchmarks as well as a full set of external reports for pay-for-performance programs and reporting to third parties including HEDIS, PQRS, ACO measures and statewide quality collaboratives.

Analytic tools – Focused on predictive modeling, episode grouping, severity & case mix adjustments

Predictive modeling tools (i.e. Johns Hopkins ACGs or Medicare’s HCCs) support proactive identification and stratification of the highest risk patients for potential referral to complex case management. A parallel methodology is also needed to measure cost and utilization with case mix adjustment, typically through episode groupers (i.e. OptumInsight’s Episode Treatment Groups or Thomson Reuter’s – Medical Episode Groups).

Remote monitoring technologies – Home-monitoring that interfaces with care management and EHRs

High-risk patients with certain chronic illnesses such as congestive heart failure, diabetes, hypertension and chronic obstructive pulmonary disease may benefit from utilizing home-monitoring devices that allow them to track their own illnesses and work interactively with a case manager and/or health coach that can also follow and track their outcomes in “real time”. This information can be sent back to both the population and care management systems and the EHRs.

Patient and family engagement technologies – Including web-based portals linked to personal health records; life style tracking tools; handheld technologies for education, tracking, reminders and interactive learning; web-video technologies for virtual provider visits, health coaching and case management; and interactive assessments, questionnaires and connectivity to measure patient outcomes and provide feedback on patient experience

Patients are now being provided access to their own medical record information and encouraged to learn more about and manage their own health risk factors and chronic illnesses. Mobile and tablet technologies, web-based patient portals and web-video technologies are allowing patients to have better access to their care teams, medical knowledge and tools that help them to improve their lifestyles and achieve better results in managing their illnesses. These can be linked to both their population and care management tools and their EHRs. Patient experience questionnaires, interactive assessments for depression screening, assessment of activities of daily living, pain management follow-up, etc. can be administered using email, patient portals and/or handheld technologies. This information can be stored and tracked in the data warehouse and the EHR as needed. Families are using some of the same technologies for social engagement and monitoring.

Population Health Information Technology is Complex to Implement but Critical for ACO Performance

All the pioneering organizations participating in the Medicare Physician Group Practice demonstration, such as Marshfield Clinic, have significantly redesigned care workflows and introduced population health information technology that makes clinical data more readily available to the practitioners and care teams, including additional “add on” disease registries or embedded tools within their EHRs.
It may be disappointing that after having spent significant amounts of time, effort and money to implement electronic medical records across your own organizations, there is more work ahead in assimilating a complete set of population health information technologies to become a successful ACO. The consolation is that none of these pioneering organizations have used all of the population health and care management tools that are now available and yet most of them accomplished positive results.

One of the keys going forward will be to prioritize the functions that are most likely to achieve results and implement those first. See the Appendix below for a matrix of Population Health IT and functionalities:

Appendix 1. Population Health Information Technology – A Patchwork Quilt

You’ve mentioned employee recruitment and retention as a big issue. What are some other trends you see in these areas in healthcare?

First off, I think healthcare is embracing the processes and technology necessary to effectively manage these processes. More and more, organizations are implementing talent management and workforce planning solutions. As part of that, better performance management practices will enable them to identify, develop and retain not just all employees, but the right ones. Additionally, as the pressures in the workplace mount, we’re starting to see a focus on quality of life initiatives.