For ACOs it's not all about the technology, but sometimes it is

By Jonah Comstock
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Emmi Solutions' patient engagement software.

Emmi Solutions' patient engagement software.

Whether intentional or coincidental, the timing of Clay Christensen's controversial Wall Street Journal editorial on "The Coming Failure of ACOs" was interesting, putting Christensen's well-rooted skepticism at the forefront of the conversation going into HIMSS 2013, where ACOs were a dominant topic of discussion. Christensen contends that ACOs will fail because they depend on an unrealistic change in attitude on the part of doctors and patients, though he sees technology, especially telemedicine, as one ray of hope.

Dr. Joseph Kvedar, director of the Center for Connected Health, responded to the WSJ piece, asserting, among other things, that Christensen underestimated both the effect of ACOs being provider-led and the game-changing potential of connected health -- certainly something that's viewed differently by peoplelike Kvedar who are immersed in digital health.

Likewise, the voices at HIMSS speaking about ACOs were not pundits speculating, but vendors and, more importantly, providers who are in the trenches of accountable care implementation. Their accounts did not tell a tale of failure -- although they did prove Christensen right about the need for a change in attitudes on the part of providers.

"Implementing technologies is the easier part," said Edward Martinez, Senior VP and CIO of Miami Children's Hospital. "Changing the way people think, and behaviors, that's what's very difficult for the organization."

"You cannot do this without physicians driving it. We had physicians leading all our teams," said Meryl Moss, Chief Operating Officer at Coastal Medical, Inc. "[You need to] focus on clinical rather than technical leadership. Our super-users were not IT folks, they were PharmDs and nurses."

Coastal Medical, a provider and ACO, won a Davies Award from HIMSS this year. The system is moving away from fee-for-service, with their doctors currently being paid 90 percent fee-for-service and 10 percent based on individual performance measures.

"Ninety-ten is not good enough, but it's the best we can do right now," said Coastal Medicine President G. Alan Kurose. "I'd like to see it be 13, then 17, then 21. If 90 percent of a doctor's compensation is still fee-for-service, he's not going to be that motivated by that."

Many of the ACOs and ACO-focused vendors at HIMSS were demoing remote monitoring and telemedicine technologies, but others suggested remote monitoring and reduced readmissions alone weren't enough to make a difference. The real key is what's called "care management" --gathering data and analyzing it to find the famed 5 percent of patients with multiple chronic diseases that represent 50 percent of the cost to the healthcare system -- and then enticing those patients to be engaged with preventative care.

"Population management is, in my opinion, a way you can reduce your costs by doing very little," said Dr. Anthony Akosa, VP of Medical Affairs for Advantage Health Solutions. "You don't want to spend your resources on everyone. Concentrate on the low hanging fruit, the 5 percent. We use analytics and claims to find that 5 percent. Make sure people who are well don't get sick. Make sure chronic cases don't move into that 5 percent."

Some of that data comes from EHRs and via remote monitoring, and it's certainly the case that more remote monitoring will make ACOs more effective by making it easier to identify those high-risk patients. Both Philips and AT&T ForHealth are making data integration a priority, ensuring that remote monitoring devices, legacy hospital devices, consumer apps, and EHRs are all speaking the same language, as much as possible.

"The enterprise integration engine recognizes the simple reality that the health system has a lot of legacy systems," said Nasrin Dayani, mHealth Solutions lead at AT&T. "And what we want to enable with our integration engine is that one single secure pipe, so they can integrate into their existing workflow. And CFOs can track all this and make sure it's helping their bottom line. We are adding healthcare-related APIs continuously."

Philips has several programs built around data integration -- IntelliBridge Enterprise is a "one-pipe" data flow solution for connected health devices in hospitals. The company's eICU telehealth system allows for better care prioritization by translating multiple ICU patients' vitals into simple visual charts which can all be compared in near-realtime on an offsite dashboard.

"If these ACOs are just facilities partnered but not sharing anything, you get nothing," said Joe Sovak, VP of Patient Care and Clinical Informatics at Philips. "That's what we're looking at systems such as our eICU program, and trying to reduce readmissions. That's where the telehealth systems come in."

Nonetheless, even the best remote monitoring technology will always be limited to patients who are already engaged with the system in some way. Much more troubling are the patients who show up in the emergency room, having never engaged with the health system previously. Because care management programs have access to Medicare claims data, they have some hope of finding these patients as well.

"The people who really need help aren't going to show up until they're really sick, and that's a bad thing, so why don't we go knock on their doors?" Dr. Richard Ferrans, Chief Medical Officer at Presence Health, a recently merged two-hospital system in Chicago, told MobiHealthNews. "So part of this is rebranding ourselves. We're a new kind of healthcare system. We're not going to wait for you to come to us when you're sick."

Ferrans pointed out that even remote monitoring can be counterproductive if it isn't deployed strategically to high-risk patients.

"One thing the early literature showed was that if you do a lot of monitoring you can improve quality and reduce expenditure, but the cost of the interventions starts to approach the savings," he said. "The benefits are if we can focus in on the patients that really will get the value and do it in a really, really scalable way."

But if identifying the patients who really need help is a challenge, an even bigger challenge lies in convincing those patients to engage with their own health and take steps to avoid ending up in the ER. Dave Pearah, Chief Technology Officer at Emmi Solutions, one of Presence Health's vendors, says a surprisingly small number of ACOs are even attempting that second step.

"When we talk to ACOs they talk about technology to identify patients and stratify them by risk, and at the end of the day they know the 7,000 diabetics with poorly controlled A1C values. But now what?" he said. "We'll send them a letter, we'll put it in the newsletter. It's like they're using 21st century technology to identify patients and then using 19th century technology to reach out to them."

Emmi's business is built around online and mobile engagement strategies to reach out to those potentially expensive patients, including interactive and gamified experiences.

"We have a full team of production folks who are writers, illustrators, and animators," Pearah said. "We obsess over the patient experience, because if we don't, patients vote with their feet. Our survival as a company depends on our ability to engage patients, and we've done nothing but that for 10 years."

The ACO providers at HIMSS echoed the sentiment that accountable care as a business model is in its early days, and many are taking what amount to baby steps in the transition from fee-for-service care to real accountability. But, as Ferrans put it, you have to learn to crawl before you can learn to walk. Health systems are moving forward and showing results, and working toward changing attitudes.

MobiHealthNews coverage of the HIMSS13 event in New Orleans is sponsored by AirStrip Technologies.

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