Look beyond 'ACO in a box' claims when assessing EHRs


The technology required for participation in an accountable care organization (ACO) is not only loosely defined, it's largely "untestable," according to Shahid Shad, software analyst and author of The Health IT Guy blog. Nonetheless, the EHR vendor community is making a subtle shift from the "meaningful use" emphasis of the past several years to a "ready for ACO" mentality.

What are the implications for healthcare entities assessing future EHR capabilities?

"Don’t be fooled into buying health IT applications that promote an 'ACO in a box' solution," cautioned Shah. "There is no such technology, and there really can’t be. ACOs are not a technology problem; they are a business model problem first, and until the business side has decided how it will identify savings – and share those savings – any purchase will likely be useless.

"The EHR systems and IT required for meaningful use [MU] is quite different from what will be required for ACOs," Shah continued. "It will be nowhere as easy for existing legacy EHRs to simply retool their current platforms, like they did for MU."

With that said, Shah outlined nine areas in which future EHRs need to support ACOs.

1. Sophisticated patient relationship management (PRM). According to Shah, today's EHRs are more like document management systems, rather than sophisticated, customer/patient relationship management systems. "For them to be really useful in ACO environments, they will need to support outreach, communication, patient engagement and similar features we're more accustomed to seeing from marketing automation systems than transactional systems."

2. Getting data from your systems through business intelligence and reporting. Meaningful use in its first stage, said Shah, is all about getting data into your systems, all with little outward sharing. "Data collection is something we've been doing for decades – even before MU came along, we knew how to build systems that could collect and store databases," he said. What most people have never been good at though, he continued, is getting data out of a system in a useful way. "Now with ACOs, business intelligence reporting, and analytics across dozens of disparate systems is a real requirement," said Shah. "Today we all have problems getting data out from a single departmental EHR to help with billing inquiries and clinical decisions support." With ACOs, he said, you not only have to pull data and tie it together with departmental and local systems in your organization, but outside your organization as well.

3. Data integration for analytics capabilities. "This doesn't mean we toss in HL7 routers and hope for the best," said Shah. Most IT environments have the ability to send messages from one system to another. "That's called transferring data, which we've been doing for decades," he said. "Integrating data, though, means much more – the ability to store and understand information in data marts, data warehouses, and clinical data stores and repositories from a variety of sources." Having an EHR, he added, doesn't mean you're ready for data integration; instead, you need tools "beyond what health IT firms provide," he said. "Traditional data integration vendors should be getting most of your attention here, as opposed to healthcare-specific [vendors]."

4.Granular clinical data sharing. The ability to integrate data into your own system is one thing, said Shah, but granularly sharing that same data across ambulatory practices, lab partners and other shared providers is going to require health information exchanges (HIEs) of varying levels of sophistication. "Early on, you might even need to try to bypass the HIEs and create your own local exchange using the Direct Project to make sure you're in control." Using the Direct Project to transfer secure data between partners — while building your data marts and warehouses outside traditional EHRs – will be "your best architecture bet," he said.

5. Payer, billing and pricing data sharing. Sharing of clinical data is one thing, said Shah, which we're used to doing in the "analog world" – think charts, documents, faxes, etc. "However sharing of financial and billing data is something most organizations don't do today and will need to get better at," he said. Regardless of how good your EHR is, or how much money you've spent on meaningful use implementations, billing and pricing data sharing is something that can't be implemented without a "sophisticated data integration strategy, so you'll need to look beyond your traditional health IT vendors here as well."

6. Aggregate data sharing. If you're not sure you can do granular data sharing for billing or clinical data, which is likely an early possibility, said Shah, you can try aggregate data sharing. "Aggregate data sharing is easier to get past governance, but most of the HIEs aren't ready to do aggregate sharing yet, [since] the standards aren't in place," he said.

7. Sharing clinical effectiveness evidence (evidence-based medicine, EBM). One important feature the CMS Shared Savings Programm for ACOs is promoting is more evidence-based medicine, said Shah. "Most of us aren't good at tracking care through EMR practices – this is another area that isn't a technical problem." In fact, he continued, everything IT professionals need for EBM exists technically. "What don't exist are the sophisticated, repeatable processes during daily care management that can track and report the EBM appropriately," he said. This isn't a standardization problem, he added, but a "typical Six Sigma business management problem."

8. Population management. According to Shah, future EHRs that want to be relevant in the ACO space will need to become "sophisticated managers of not just charts for patients, but comprehensive patient population management." This includes tracking the latest eMeasures, understanding the needs of groups of patients, and allowing the creating and execution of worklists to help manage patient populations, "such as help desks and calling out to patients [who] need special attention," he said.

9. Change management. "ACOs will require numerous changes in the various organizations that take part," said Shah. "EHRs that understand that change management, which allow tracking of multiple projects and tasks, will be most useful." Today's EHRs are more focused on retrospective document management, Shah continued, but tomorrow's EHRs need to help define, encourage and manage change within the organization.

Image attributed to kunal via Creative Commons license.