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8/12/2011
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10 Mistakes Accountable Care Organizations Still Make

Successful ACOs require new health information exchanges, better EHR functionality, and the ability to measure true outcomes. Two experts say we're not there yet.

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When the Centers for Medicare and Medicaid Services (CMS) announced its proposed regulations for accountable care organizations (ACOs) last spring, CMS administrator Donald Berwick said "information management--making sure patients and all health care providers have the right information at the point of care--will be a core competency of ACOs."

In a new article about ACOs in the Journal of the American Medical Association, two other health policy experts reaffirm the importance of health IT, including electronic health records (EHRs), in building these organizations. At the same time, they point out that the technology is not yet up to the task.

In the paper, Stephen Shortell, dean of the school of public health at the University of California, Berkeley, and Sara Singer, of Harvard's school of public health, offer a list of 10 mistakes that ACOs may make. They are:

1. Overestimation of ability to manage risk.
2. Overestimation of ability to use electronic health records.
3. Overestimation of ability to report performance measures.
4. Overestimation of ability to implement standardized care management protocols.
5. Failure to balance the interests of hospitals, primary care physicians, and specialists in creating governance and management processes to adjudicate differences.
6. Failure to sufficiently engage patients in self-care management and self-determination.
7. Failure to make contractual relationships with the most cost-effective specialists.
8. Failure to navigate the new regulatory and legal environment.
9. Failure to integrate beyond the structural level.
10. Failure to recognize the interdependencies and therefore the potential cumulative "race to the bottom" of the above mistakes.

The ability to use EHRs effectively in ACOs, the authors write, can be hampered by: inadequate training and support from clinicians; disruption of practices during the early phase of implementation; and incompatibility of hospital and ambulatory-care systems.

The experience of pay-for-performance programs shows the difficulty of collecting, reporting, and analyzing performance data, Shortell and Singer noted. They predict that this reporting capability will gradually evolve over time.

In an interview with InformationWeek Healthcare, Shortell said that healthcare organizations' ability to collect and report quality data as part of Meaningful Use varies greatly across the country. "We've seen some medical groups that have EHRs that incorporate a lot of those measures, and they can capture the data and report it. But a lot simply can't. They don't have the functionality yet [in their EHRs]."

Most ACOs will also require health information exchanges to improve the continuity of care, he said. "Even those that have very sophisticated systems within silos have a problem linking them up when patients go to other doctors, are referred to hospitalists, or are hospitalized. For that, you either need a closed system like Kaiser or information exchanges that will be able to capture and aggregate that data."

One identified potential flaw in ACOs is the "failure to sufficiently engage patients in self-care management and self-determination." While few of the fledgling ACOs have experience in this kind of activity, Shortell said that health IT can play in important role in patient engagement.

"Email and other forms of online communication are a powerful means of engaging people," he pointed out. "Another part of it will be continued advances in home monitoring technologies for diabetes, asthma, and other chronic diseases. As those technologies become more cost competitive and more prevalent in people's homes, they will help engage people in their own care by monitoring blood pressure, glucose levels and so on."

The JAMA article also noted that the failure to achieve clinical integration could sink some ACOs. Again, Shortell said, health IT will be needed to map out processes of care and generate feedback on how the changes in care delivery are working. "That's where the electronic health record can pay off."

In the long run, the paper points out, ACOs will have to develop "a mature performance measurement system to provide rapid feedback about what works in different local environments." According to Shortell, this means "the ability to have accurate measures across the continuum of care on the key metrics you'll need to manage the population--particularly the high cost [of] chronic disease patients. A mature measurement system would be able to capture the total cost of care for that episode of illness. We can't do that currently."

In addition, he said, such a system would incorporate two other key outcomes measures: functional status and patient experience. "Almost no one in the country that has that level of performance maturity," he said. "Kaiser might approach it."

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