atrius health pioneer aco clinical intelligence &...

ATRIUS HEALTH

PIONEER ACO

CLINICAL INTELLIGENCE & BUSINESS INTELLIGENCE

January, 2013

© 2013 Healthcare Information and Management Systems

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INTRODUCTION 3

BACKGROUND AND PURPOSE 3

STUDY POPULATION AND APPROACH 4

ATRIUS HEALTH 5

ORGANIZATIONAL BACKGROUND 5

VISION 6

MISSION 7

VALUES 7

ON BEING A PIONEER ACO 7

CLINICAL INTELLIGENCE APPROACH 8

GOALS 8

APPROACH TO ACCOMPLISH GOALS 9

BUILD AND SUSTAIN MOMENTUM 12

CLINICAL & PHYSICIAN IMPACT 12

BUSINESS INTELLIGENCE APPROACH 13

MATURATION AND EVOLUTION 13

FOUR BI PRESENTATION MARKETS 14

SHORT TERM TARGETS 16

CONCLUSION 17

ABOUT HIMSS ANALYTICS 18

ABOUT THE AUTHOR 18

APPENDIX A 19


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Introduction

pi·o·neer noun \ˌpī-ə-ˈnir\

A person or group that originates or helps open up a new line of thought or activity or a

new method or technical development.1

The growth of the United States as a nation is indebted to “pioneers”. In American culture,

pioneers are best represented by those who went into the unexplored territories of the West in

search of a new life, looking to establish a permanent settlement. But the role of the pioneer in

our nation’s life is not relegated to a bygone era. Pioneers are present in our healthcare system

today blazing paths toward sustainable delivery models of care. For example, the Centers for

Medicare & Medicaid Services (CMS) Innovation Center (Innovation Center), has created the

Pioneer Accountable Care Organization (ACO) program with the intent of creating pioneers to

explore a new frontier of healthcare. In December 2011 CMMI awarded 32 organizations the

title of “Pioneer ACO”.

“Pioneer ACOs are leaders in our work to provide better care and reduce health care costs,”

said Secretary Sebelius. “We are excited that so many innovative systems are participating in

this exciting initiative”2

Kathleen Sebelius, US Secretary of Health and Human Services (HHS)

So what does the path look like so far for those leading the way? With the first year of a three-

year journey behind the Pioneer ACOs, HIMSS Analytics has taken an opportunity to discuss

pioneer progress with Atrius Health, one of the Pioneer ACO leaders.

Background and Purpose

HIMSS and its research arm, HIMSS Analytics, have seen a tremendous interest of late in the

use of Clinical and Business Intelligence (C&BI) tools and processes to improve clinical

outcomes, enhance and monitor healthcare business operations, and to manage patient

populations. This interest appears to stem from a multiplicity of forces converging together to

elevate the importance of healthcare intelligence in response to healthcare reform drivers.

Forces range from the expansive adoption of evidence based medicine to new payment

methodologies such as Accountable Care and the Patient Centered Medical Home approaches.

These new models of care require clinical intelligence and business intelligence at levels not

typically seen in healthcare. Implementing C&BI tools such as predictive modeling, population

management, care coordination, electronic health information exchange, etc… requires a

certain “frontiersman spirit” to travel a trail that is not well worn in today’s healthcare landscape.

1 http://www.merriam-webster.com/dictionary/pioneer , 7/12

2 News Release, http://www.hhs.gov/news/press/2011pres/12/20111219a.html , HHS Press Office,

December 19th, 2011

http://www.merriam-webster.com/dictionary/pioneer

http://www.hhs.gov/news/press/2011pres/12/20111219a.html


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Thirty-two (32) Pioneer ACOs were chosen through an open and competitive process from a

large applicant pool that included many diverse organizations. These 32 organizations brought

experience offering coordinated, patient-centered care, and experience operating in ACO-like

arrangements.3

The Pioneer ACO Model is a CMS Innovation Center initiative designed to support

organizations with experience operating as ACOs or in similar arrangements in providing more

coordinated care to beneficiaries at a lower cost to Medicare. The Pioneer ACO Model will test

the impact of different payment arrangements in helping these organizations achieve the goals

of providing better care to patients and reducing Medicare costs.4

Extensive information on the Pioneer ACO program can be found on the Innovation Center’s

website at http://innovations.cms.gov/initiatives/aco/pioneer/.

All the Pioneer ACOs are unique in organizational structure, technical infrastructure, size and

approach to care; as such, each has a unique history as well as a story to share about their

planning, success and progress towards reinventing healthcare in the accountable care model.

HIMSS Analytics worked with Atrius Health, one of the 32 Pioneer ACO’s, to present their

unique perspective on how they approached management and delivery of care to their assigned

beneficiaries. This white paper will provide a benchmark of the approach Atrius has taken to

manage two critical components of their Pioneer ACO, their clinical intelligence and their

business intelligence.

Study Population and Approach

This white paper is based upon research and in depth interviews with key executives driving the

Atrius organization. These interviews were parceled into roughly three sections. The first

focused on an overview of the organization; the second set of interviews focused on the

organization’s approach to clinical intelligence; and the third addressed the organization’s

approach to business intelligence. The concept is to orient readers to the organization in

general and then specifically narrow the focus into the clinical and business intelligence

approaches used to facilitate ACO efforts.

The distinction between Business Intelligence (BI) and

Clinical Intelligence (CI) in a healthcare organization can

be a challenge. Sometimes decisions in healthcare are

clearly all business and stand out as BI, such as contract

negotiations or facility management. CI, on the other

hand, can be described as when computer based

analytical and reporting methods are used in an effective

way to support or improve patient care. For example,

using lab results to confirm a diagnosis or mapping patient population demographics for

analyzing and managing ER utilization in a region are examples of using Clinical Intelligence.

3 http://innovations.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf , CMS, 7/12

4 http://innovations.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf , CMS, 7/12

Business Intelligence

Clinical Intelligence

http://innovations.cms.gov/initiatives/aco/pioneer/

http://innovations.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf

http://innovations.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf


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Other times BI and CI can overlap. For example, in making a staffing call schedule, there is a

financial component that translates into business intelligence as well as a clinical component

that translates into having the right resources to deliver the quality and quantity of care needed.

BI and CI in healthcare exists in an overlapping Venn diagram that fluctuates based on the

decision at hand, point of view, and the availability and sophistication of the data and tools

leveraged to support those decisions.

Atrius Health

Organizational Background

Atrius is derived by combining the words "Atrium" and "Radius". "Atrium" is an open central

court or dedicated special space, and also a chamber in the heart. "Radius" defines a circle or

sphere, or is a measure of range of activity or influence. When joined, "Atrius" means a special

dedicated space defined by the relationship between the patient - at the center - and his/her

physician and medical team.5

Atrius Health, a nonprofit alliance of six multi-

specialty medical groups, was created in 2004 to

enable collaboration on new and better ways of

delivering care, transform the delivery of health care

in eastern and central Massachusetts, while

maintaining an emphasis on care for the local

community. Atrius employs over 7,200 employees

including 1,000 physicians and more than 1,425

other healthcare professionals. These staff service

3.8 million visits from over one million adult and

pediatric patients utilizing approximately 50 sites

across Eastern and Central Massachusetts.

5 http://atriushealth.org/aboutUs/faq.asp , Atrius Health website, 7/12

http://atriushealth.org/aboutUs/faq.asp


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The 2012 Atrius Health Pioneer ACO is comprised of five of these six medical practice groups:

Dedham Medical Associates

Granite Medical Group

Harvard Vanguard Medical Associates

South Shore Medical Center, and

Southboro Medical Group

Reliant Medical Group joined Atrius Health in October 2011 and will participate in the Pioneer

ACO starting in 2013.6 Currently the Atrius Pioneer ACO program has been assigned and

services approximately 26,000 patients. In 2013, Reliant will add another 3,500 additional

patients bringing the total number of patients served to approximately 29,500. With 26,000

Medicare Advantage patients and Reliant’s additional patients, the total Medicare population for

Atrius will hover around 55,000. Atrius currently derives approximately 70% of its revenues

from risk based patient populations.

“All of these [practice] groups come from an experience with the infrastructure that it takes and

the mentality that it takes to think about total medical expense and to think about quality across

the continuum”

Dr. Rick Lopez, Chief Physician Executive

Atrius has a “commitment to quality”7, according to Dr. Lopez, as demonstrated by the extensive

quality measures posted publicly on their website. The key focus of the organization is striving

for the “Triple Aim” which is to simultaneously;

Improve the patient experience at an individual level through the use of tools such as

individual care plans

Achieve population health improvement; and

Reduce the per capita cost of care8.

Atrius Health, the largest independent alliance of community based physicians in

Massachusetts9, works closely with leading academic medical centers and community hospitals

to coordinate care across the continuum for their patients. The Atrius Health groups have been

leaders nationally in their advanced use of health information technology (including a patient

portal for secure electronic communication), chronic disease management, clinical pharmacy

programs, Lean care improvement and innovative ways of delivering care such as shared

medical appointments.

Atrius Health defines their vision, mission and values as follows:

VISION

6 http://atriushealth.org/aboutUs/whoWeAre.asp , Atrius Health website, 7/12

7 Dr. Rick Lopez, Atrius Health Chief Physician Executive, 7/26/2012

8 http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx , 7/12

9 Dr. Rick Lopez, Atrius Health Chief Physician Executive, 7/26/2012

http://atriushealth.org/aboutUs/whoWeAre.asp

http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx


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By partnering with our patients and communities to make it easier to be healthy, we

measurably improve their health.

MISSION

Atrius Health supports its member groups to improve the health of their patients and

communities.

VALUES

Each Atrius Health member group individually and collectively embraces these values as

noted on the Atrius Health website…

We practice patient-centered care, seeking to know our patients as individuals, offering

compassionate care that respects their unique needs, and responding to their feedback to

continuously improve their care.

We respect that the cornerstone of our practices is to deliver the highest possible quality to

our patients in the safest environment within their local communities.

We value teamwork led by clinicians collaborating with engaged and talented staff.

We shape the future of healthcare by innovating new ways to care for our patients, promoting

research and educating the next generation of clinicians.

We deliver equitable health care that is evidence-based whenever possible to all of our

diverse patient populations.

We endeavor to be good stewards of our resources in order to extend care charitably,

efficiently, and more broadly to our communities.

We aspire to integrate our information and services across diverse communities to create a

seamless system of care for our patients.

We believe our mission is best served by retaining the identity, independence, and diversity

of the member groups.

On Being a Pioneer ACO

Dr. Gene Lindsey, CEO of Atrius Health reports he is “very pleased” with the organization’s

Pioneer work six months into the program. He notes that for the first time in its history, the

organization is employing the same principles for all health plans, regardless of payment model.

“We are recognizing that we need to up our game on patient experience and we need to link

more closely with the continuum [of care] than we have in the past”. This all means tighter

coordination between Atrius Health physicians and those that provide supporting services such

as skilled nursing facilities and hospitals.


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“We also adopted a relatively unique concept in that we wanted to take care of all of our patients

exactly the same, no matter what their funding mechanisms were. So we've combined our ACO

population with our Medicare Advantage population.”10

Dr. Gene Lindsey, CEO of Atrius Health

Combining their ACO population and the Medicare Advantage programs includes setting up

arrangements that are more consistent and systematically better at providing the high quality

care at a competitive price that Atrius needs to meet its performance goals. Referrals are more

tightly directed and coordinated than in the past, as well as working with care continuum

partners to ensure quality and patient care meet specific standards. “There is a more strategic

goal here, of stepping up the game in terms of our performance so we can reach higher quality

that is more cost effective for all our patients” says Dr. Lopez.

Dr. Lopez’s advice for those thinking of starting or joining an ACO, “Go… get started”.

Clinical Intelligence Approach Goals

As Chief Physician Executive, Dr. Lopez is accountable for Atrius Health’s’ clinical intelligence

efforts. Dr. Lopez clearly sees Atrius Health having two primary goals surrounding clinical

intelligence:

To reduce Atrius Health’s cost so that it operates two percent under the official Medicare

“reference population” trend, thereby allowing Atrius Health access to the savings they

earned. This is basically bending the cost curve two percent relative to the baseline

population.

To effectively report on the 33 quality metrics required of all Pioneer ACOs from the

Innovation Center.

These are goals that should not be underestimated as assigned patients are still free to choose

where and when they receive care, even outside of Atrius’ providers and network of partners.

Dr. Lopez states “The Pioneer program was designed to create a higher level of risk taking and

more focused on healthcare delivery systems that had more experience at managing care.” In

this regard Atrius Health’s experience working with Medicare populations and managing at risk

contracts would serve it well.

10 The ACO Shared Savings application process - FierceHealthcare,

http://www.fiercehealthcare.com/special-reports/atrius-ceo-interview-inside-pioneer-aco/aco-shared-savings-application-process#ixzz1ywZVYK58 , 2/24/2012

http://www.fiercehealthcare.com/special-reports/atrius-ceo-interview-inside-pioneer-aco/aco-shared-savings-application-process#ixzz1ywZVYK58




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Approach to Accomplish Goals

Each practice group within Atrius Health is independent and has its own leadership, operations

and approach to managing day-to-day activities. For these groups to come together and have

clinical leadership as well as identify the areas they needed to improve on, they needed a focal

point. Atrius Health therefore hired an ACO Executive Director to coordinate and manage the

interaction between participating organizations and to facilitate Pioneer ACO efforts, including

coordination with the CMS Innovation Center. One of the first tasks for this director was the

creation of clinical workgroups to focus on four specific areas.

Hospital Strategy

Post-Acute Facility Strategy (managing patients in skilled nursing facilities, etc…)

Home Care Strategy

Geriatric Care Model Design

Each workgroup included both a clinical and operational leader.

Workgroup 1 - Hospital Strategy

Atrius Health does not own a hospital; instead, the organization’s ACO strategy was to develop

strong, close working relationships with hospital partners. Atrius Health first identified those

hospitals their patients typically used and worked closely with those organizations to create a

“preferred hospital partner” designation. Atrius Health then defined their patient care

expectations which were then shared and reviewed with the various preferred hospital partners.

The expectations included the following:

Efficiency in the emergency department

Quality of care standards

Care management

Discharge planning / management

Readmission management

Interoperability and access to clinical information

Timely notification upon patient presentation/admission/discharge, and

Return referral of patients back to Atrius Health, or if discharged to a home care agency,

a referral to one of Atrius Health’s preferred partners.

This list set an expectation of patient management and care coordination not typical across

today’s healthcare environment. A chart representing the key elements of these expectations

by area of focus is included as Appendix A.

In order to monitor performance against these expectations Atrius Health created a scorecard

that tracks performance and is shared with the hospital on a regular basis. Governance

structures within Atrius Health’s preferred hospitals use this scorecard to manage the

relationship and interaction between the two organizations. Scorecards rely on a multiplicity of

data sources to track utilization, clinical care processes and benchmarking. The scorecard also

provides the opportunity for discussion between the organizations providing care.


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Governance involves hospital CEOs, key leaders and the ACO Executive Director meeting

multiple times per year allowing for ongoing dialog and improvement of coordination from

executive management down. Governance activities result in workgroup creation, such as an IT

workgroup or a clinical operations team, to ensure systems and clinical processes are set up

and integrated both intra- and inter-organization to facilitate expectations.

Dr. Lopez was clear to note that the provider expectation list was not a one-way street. Atrius

Health expects the preferred provider hospital leaders to define their expectations of Atrius

Health. This didactic exercise creates strong two-way dialog between the Pioneer ACO and key

supporting provider organizations that encourages care coordination and communication.

Workgroup 2 - Post Acute Care Facility Strategy

Dr. Lopez identified skilled nursing facilities (SNF) as an important component of care for Atrius

Health to manage. With the care provided in these facilities representing 15 to 20 percent of the

Atrius Health’s care spend, it was essential for Atrius Health to quickly establish a preferred

provider SNF network. Atrius Health therefore employed the same approach noted above for

hospitals, in managing the relationship with post-acute care facilities, with a few additional

components. These additional components include expanding the creation of standards for the

physician, nurse practitioner (NP) and nurses that are managing patient care. These care

standards are specifically focused on the types of care managed in a SNF and are generally

different than those presented to a hospital.

Atrius Health staff are always required to follow agreed upon care standards and facilitate

execution of the Atrius Health standards when interacting with SNF staff in any location,

regardless of local standards and practices that may vary from Atrius Health standards. Atrius

Health works to ensure these SNF standards are consistent across all their patient populations

and facilities.

Workgroup 3 - Home Care Strategy

To gain access to a strong home care network and minimize overhead, Atrius Health signed a

strategic agreement with the Visiting Nurse Association (VNA) Care Network11. “We made them

our singularly preferred VNA and have brought them into our workgroup discussions around

how we want to manage care in the home” said Dr. Lopez. “We want to think about ways we

can provide home care services that are more innovative, meeting the needs of the patient

where they live, more than just having a nurse come in and take their blood pressure where the

patient lives, more intensive programs around certain conditions like congestive heart failure

and high risk patients”.

11 http://www.vnacarenetwork.org/ , VNA Care Network & Hospice website, 7/12

http://www.vnacarenetwork.org/


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Coupled with the VNA contract is an approach to work with Aging Services Access Points

(called ASAPs, in Massachusetts12). ASAPs are one-stop entry points for all of the services and

benefits available to seniors in Massachusetts. ASAPs manage the state-based Massachusetts

Home Care Program and work with Area Agencies on Aging (AAAs), established under the

federal Older Americans Act, to ensure seniors have access to all essential services.

ASAPs offer the following services for seniors and caregivers according to the

massresources.org website:

Information and referrals for senior services, including home care services, housing options,

public benefits, legal assistance, hospice care, the ombudsman program, health insurance, senior

companions, and adult day care

Elder care advisors

Protective services, to prevent the abuse, neglect, or financial exploitation of seniors by their

caregivers

Elder-at-risk services, to protect seniors who may need help to live safely and independently at

home

Case management for eligible seniors, including

o needs assessment

o screening and eligibility determination for institutional or community-based long-term care

o development of a service plan

o help with applications for public benefits

o coordination and purchase of needed services

o monitoring and reassessment of needs

Caregiver support

Nutrition services

Online resources; printed booklets and fact sheets; lending libraries

Some services are offered to seniors free of charge, while other services are only available to

seniors who meet program eligibility requirements.13

Atrius Health is working on a way to involve the ASAPs in a global payment environment.

Workgroup 4 - Geriatric Care Model

Atrius Health’s Geriatric Care Model workgroup is responsible for defining the organization’s

standards around geriatric care. This workgroup covers a range of topics including the kinds of

patients to be reviewed, how these reviews are to be conducted, who should participate in the

reviews, and how the clinical units of each practice group should implement these standards.

The Atrius Health workgroup came up with a “Roster Review” model that sets specific geriatric

care standards. Each of the five participating practice groups in Atrius Health then implements

those standards in a way that works best for their practice. So while there may be variation in

12 http://www.mass.gov/elders/homecare/aging-services-access-points.html , Commonwealth of

Massachusetts website, 6/12 13

http://www.massresources.org/senior-agencies.html#asaps , Community Resources Information, Inc., 6/12

http://www.mass.gov/elders/homecare/aging-services-access-points.html

http://www.massresources.org/senior-agencies.html#asaps


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technique, all of the practices apply consistent standards and are held accountable for

performance.

Typically each practice will hold a weekly Roster Review session where patients that meet the

review criteria are discussed in detail. Documentation is created and managed in a structured

and standardized format, documented in the patient’s electronic medical record (EMR) so

metrics can be tracked and reported. For example, one standard requires that fall assessments

be completed on 80 percent or greater of qualifying patients. This is discussed and managed in

the Roster Review session for appropriate patients and assessments are documented, tracked

and reported. By doing so, each practice group tracks its performance against the agreed upon

standards and against each other. Performance and benchmarking reports are shared across

all groups.

“Wherever you create standards, if you don’t align that with metrics, you are not holding each

other accountable and you not ensuring that the work gets done”, said Dr. Lopez.

Build and Sustain Momentum

The Atrius Health leaders interviewed readily acknowledged the importance of fostering the

creativity and innovation that each practice group offers in order to allow them to perform at

what they do best. These same leaders were quick to note the challenges of allowing standards

to be developed at the practice group level on one hand, and ensuring accountability and

consistency with reporting and metrics on the other. To foster this creativity, Atrius Health

established a monthly event called “ACO Day”. On ACO Day, all of the clinical leaders come

together for an entire morning or afternoon. Each of the Atrius Health 4 workgroups mentioned

above gives a one-hour presentation that outlines current activities. This aligns everyone on the

same page of effort for each group. Another 90 minutes is spent in segregated workgroup

meetings. Finally, one hour is allotted so clinical leaders and staff can participate in a learning

collaborative involving education and best practices presentations followed by open discussion

about a specific singular topic. This provides the opportunity for some of the innovation of

leading groups with proven approaches to share with the entire organization. ACO Day “keeps

everybody in sync and keeps everybody accountable”, Says Dr. Lopez.

Clinical & Physician Impact

To support the clinical intelligence efforts of the ACO, several of the practices in Atrius Health

have hired additional staff to facilitate their Pioneer ACO work. While each practice evaluates

their individual needs and develops their own unique solutions, they are all held to common

reporting and benchmarking standards facilitated through Atrius Health and driven by CMMI

financial and quality metrics.

The workgroups create opportunity and environments where clinical intelligence activities

flourish. These activities are manifested in collateral such as the Roster Reviews, the geriatric

care standards, and care coordination activities.


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While the focus and intent of these activities is to have an outcome that demonstrates Atrius

Health is a successful Pioneer ACO, the efforts are spilling over into other populations groups

served by Atrius Health, such as the Medicare Advantage and private payor populations.

According to Dr. Lopez…

“We have a strong infrastructure to begin with…what we see at the front line is more case

managers, there are more social workers walking around the halls, there are Roster Reviews

that are being pushed, and there is more focus on which hospitals are we using and more

attention paid to patients that are being readmitted and why that happened.”

Moreover, Dr. Lopez reports there is an increased intensity on how Atrius Health practice

groups are doing their work and a concentrated focus on doing it better. “It’s a combination of

more resources, new processes, incentive changes, it’s not a dramatic jump off the cliff, but it’s

a steady evolving set of dynamics that are happening at the practice level”.

Feedback from physicians has been very encouraging. For example, physicians report there are

more support personnel to take care of the patients. Staff physicians can turn to these

resources for special services like fall prevention assessments and care coordination.

Physicians have also spoken positively about the processes used to manage their panel of

patients. Practice groups are more sensitive to the needs physicians have in allocating the

appropriate time for such things as meeting with care managers to review cases or seeing

patients in an exam room. One practice group has carved out regularly scheduled time for

physicians to handle these new activities. In addition physician compensation is gradually

moving toward value driven metrics instead of volume according to Dr. Lopez. He noted…

“Compensation is being based on, in part, your quality scores, or your patient satisfaction

scores, or the size of the panel of patients you care for as opposed to just the numbers of visits

you generated. Each of the [practice] groups is moving more steadily in that direction…and of

course that changes the way physicians think”.

Business Intelligence Approach Maturation and Evolution

“It used to be, five or six years ago, there was a lot of overlap on what was done centrally and

what was done at the individual sites…as we have matured as a department I think it’s clear

that our central [IT] department really is focused more on our core BI competencies”

Dr. Joe Kimura, Medical Director of Clinical Reporting and Analytics

Dr. Joe Kimura, Medical Director of Clinical Reporting and Analytics at Atrius Health, notes that

provider groups pay a fee for IT services facilitated through Atrius Health. This fee covers the

costs associated with such things as hardware and software applications, connectivity, their

Electronic Medical Records (EMR) system, reporting tools, DRG groupers, risk management

tools, patient experience reporting, desktop tools, etc… A centralized IT environment enables

efficient IT management and economies of scale for pricing and support. The centralized


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approach also allows for an investment in tools that increase value of the data that otherwise

would not be possible if the data and funding were segregated and isolated by provider practice

or facility location.

Dr. Kimura’s team can leverage tools such as APR-DRG groupers from 3M and First DataBank

pharmaceutical pricing, which allows identification of care management opportunities, and verify

and validate pricing and be aggressive about using business intelligence (BI). The utilization of

these centralized tools and resources is done with an eye towards filling gaps, in areas such as

analytics, which add value to the organization as a whole. These solutions would not be

practical if patient data or analytical tools and staff resources were distributed because the costs

would be higher and the data incomplete. The central data warehouse, data integration,

standard definitions, and accessible easy to use data marts are critical to empowering their

business. These efforts not only empower centralized BI, but engage local facility analysts

which help the clinical and business teams use the data and resources in support of physicians

and their teams. There is typically one analyst per site and if data is entered incorrectly, the

analyst is usually the first to spot the results and give feedback to the physician and their team

on how to correct the issues. This approach allows global tasks and resources to be leveraged

for the common good and local tasks and priorities to be prioritized and managed at the local

level. Dr. Kimura states…

“We [centralized resources] do a lot less of those ad-hoc requests that come in from the front

line, we will do a lot more of the larger ad-hoc stuff for the executive team…global enterprise

wide analytics”.

While Atrius Health does license advanced reporting tools, “Microsoft Excel is the tool of choice

for the front lines” notes Dr. Kimura. A physician will use the standard pre-formatted reports to

identify an area of interest, such as a particular patient panel, then a local analyst will respond,

typically standing next to the physician, and facilitate dumping that data into an Excel

spreadsheet. This minimizes the quantity of custom report requests and allows a quick, local

response. These spreadsheets can then be quickly manipulated with key data fields and sorting

tools by the physician.

Four BI Presentation Markets

“Anything that we do clinically has to be supported with the business, both with an operationally

efficiency and cost perspective, but as well with patient experience” notes Dr. Kimura. To that

end, effective data collection, integration, governance and reporting are critical. Above and

beyond the 33 quality metrics the Pioneer ACOs are mandated to report, Dr. Kimura has

identified four primary business intelligence markets within Atrius Health:

Executive Team/External Partners

Director and Site Based Administrators

Physician and Line Managers

Patients


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Each market requires different types of data, different breadth and depth, and different access,

and most interestingly each of these markets has a different level of maturity.

Executive Team / External Vendors

High level summaries and how Atrius Health is trending across all six medical groups, and

performance as individual groups, are naturally part executive team management. Executive

reporting provides Senior Leaders a high-level summary out of the organization’s performance

overall and by individual group. Dashboards reflect the 33 Pioneer ACO-mandated metrics and

have tools that drill down to the individual physician level. This allows the VP of Quality to

evaluate the organization’s performance at multiple levels of analysis. For example, a diabetic

performance metric that rolls up to a global Atrius Health/Pioneer performance metric would

have drill down dashboard designed to show how the team supporting the physician and their

processes were executed, as well as the physician, to meet that diabetic metric. Low

performing teams or individuals can then be identified in specific ways that allow targeted

training and education. High performing pods can be mined for best in class processes and

techniques.

While leaders have the ability to isolate a single physician’s performance, the leaders we talked

to were quick to point out their appreciation for the team aspect of care. Atrius Health

developed this quality measurement and tracking infrastructure and approach based on their

experience with their Blue Cross Blue Shield Alternative Quality Contract (AQC). It now serves

as an executive management quality benchmarking tool across not only their Pioneer ACO

population but all of their “at risk” patients. Atrius Health uses this high-level data to predict

where their performance will track over time and to maximize the return on quality improvement

efforts.

Director and Site Based Administrators

Each Atrius Health site has a local director and site administrator. These are the traditional

“power users” of Atrius Health data and systems; they have an eye to operations and have an

understanding of the global operations. They have to make judgment calls using business

intelligence on where investments in resources will yield the most value within their areas. This

area has traditionally been the primary focus of services and reporting form the centralized IT

service area and represents the most demanding and highest volume of user needs.

Typical third party solution vendor presentations and focus are to this user base. Atrius Health

has been encouraging vendors to cater to some of the other data presentation markets they

have identified.

Physicians and Line Managers

Atrius Health originally created one set of tools geared towards this power user market and

worked to transfer and leverage them across the other BI consumers within the organization.

Eventually it was acknowledged that the complexity of the analytics requested by the power


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user group was too much for the other groups to consume. Atrius Health came to the

conclusion that they needed tools with a stronger eye towards usability and with a visual display

geared towards executives and front line physicians. This led to the creation of a business

intelligence presentation layer that was easier to consume for both the executive and physician

BI markets. The litmus test Dr. Kimura uses…

“It’s got to look like a Japanese Zen garden and not the Las Vegas strip”

Patients

Atrius Health feels they are still in the early stages of dealing with data presentation for patients.

Built into the Atrius Health EMR system is a patient portal and they are sensitive that taking into

account mobile technology is clearly a big part of how to best engage patients going forward.

One key focal point is how to begin to display more complex information for patient consumption

that allows them to be more directly involved in the decision process. The first approach for

addressing this need is a patient-centric report created in the EMR for sharing between the

physician and the patient. The report serves as the basis for care decision discussion. This

report primarily focuses on care delivered within the Atrius Health system since other claims

data feeds have a delay. Efforts are being made to acquire timely external data in more detail

to support better a better patient engagement solution.

Short Term Targets

Beyond the day-to-day operations Dr. Kimura and his team have to be managing their

infrastructure and tools in a way that aligns with the organizations strategy and evolves as the

market and capabilities mature. Any infrastructure that is stagnant, especially in today’s super

charged healthcare IT environment, is one that is quickly outdated. Dr. Kimura has identified

three areas of focus for the short-term to maintain Atrius Health’s leading edge.

Natural Language Processing

“Natural Language Processing (NLP) is definitely an area we want to get into… we have enough

people interested and the technology seems to of matured sufficiently”, says Dr. Kimura. The

challenge is creating an opportunity to test the tools in a way that minimizes the risk. Physicians

have traditionally used voice dictation to transcribe encounters. Voice translations to text are

still not the equivalent of or as valuable as discrete data entry, which is tedious and takes more

time.

Addressing “Malignant Outside Utilization”

Often when patients are cared for in an external facility they may be referred to a specialist

outside the Atrius Health network. This referral can lead to multiple other referrals, and so on,

escalating the out of network activity in a costly and uncontrollable way. Atrius Health has an

internal name for this business situation called “Malignant Outside Utilization”, or MOU. The


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Pioneer ACO program along, with other new programs sponsored by CMMI, do not limit patients

to only receiving care from their assigned organization. The challenge for Atrius Health and

others is to minimize outside referrals as well as educate patients regarding preferred options.

Tracking claims and referral patterns is an analytical challenge, especially since not all claims

have referral numbers. Atrius Health has started exploring uses of organizational network

analysis or network analytics strategies to identify referral patterns as revealed by claims data,

tracking back to the root, or initial instance of outside referral. This will reveal common practice

patterns and pathways for MOU and help identify the most active source nodes. Attaching

dollar amounts to these nodes and specialists will reveal the most heavily utilized referral

patterns and their financial impact. Atrius Health is currently working a pilot of this program

against their claims data.

This pilot, a sophisticated leading edge BI effort, directly compliments and supports the strategic

efforts undertaken by Atrius Health to work with its acute care and SNF partners on setting care

standards, which include managing referrals to preferred care specialists. Dr. Kimura states…

“Classically we have just listed out outside utilization dollars, but the network [outside referral]

maps give a much more compelling display of causality and demonstrates how that pathway

can be eliminated”.

Geographic and Spatial Analysis

Atrius Health has been using geospatial analysis of events, leveraging zip code and claims data

to identify hot spots for particular types of events such as hospital admissions, ED visits, or

other metrics such as brand vs. generic pharmaceutical utilization. This will allow Atrius Health

to partner and work with communities, which allows the communities to be more proactive about

how can help manage the health of their population. Creating analytics not in a delivery system

centric way but a community centric way is the next direction. It has been said the heart of

healthcare is in the community.

There is a small coalition in Boston that has brought together community leaders, directors from

community health centers, and Atrius Health to see if they could all work together to improve the

communities health. They are linking air quality measures, police crime statistics, school

truancy data, ED visits, motor vehicle accident data, and other data to help the community

decide how to address their most pressing health concerns. While the BI and analytic tools to

derive these results are still new to Atrius and being developed, the organization feels this is the

next logical step in accountable care and managing health care costs at a broader level.

Conclusion The forerunners of the Wild West were challenged to fill their wagons with what they needed to

sustain their livelihood in uncharted territory. Often times, they brought baggage from their

previous lives that had no place in the frontier. Atrius Health has carefully selected a package

of capabilities that allows them to work in the new ACO frontier. In many cases they have made

their own reports and priorities reflecting the importance they place upon quality measures,


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consistently coordinated care, population health management, and individual patient

accountability. Their tools and techniques are young and simple, but appropriate and easily

refined and improved.

Atrius Health has harnessed a powerful set of capabilities to manage an ACO population by

leveraging its physician practice expertise, a centralized and supportive IT department with a

complete EMR and supporting data warehouse, and strong communication and internal

coordination. Further, Atrius Health appreciates it can’t do it all on its own has is aggressively

working with its external partners, such as hospitals and SNF’s, to set consistent standards for

normalized patient care and with other organizations to reach patients wherever they need care.

Atrius Health is truly a pioneer, plying their expertise in delivering managed care and rallying

those around them. They have carefully chosen a trail that allows them to leverage their

organizational strengths and is aligned with their vision and serve as a great example for those

that will follow.

About HIMSS Analytics HIMSS Analytics is a wholly owned not-for-profit subsidiary of the Healthcare Information and

Management Systems Society (HIMSS). The company collects and analyzes healthcare

information related to IT processes and environments, products, IS department composition and

costs, IS department management metrics, healthcare trends and purchase-related

decisions. HIMSS Analytics delivers high quality products, services and analytical expertise to

healthcare delivery organizations, healthcare IT companies, state governments, financial

companies, pharmaceutical companies, and consulting firms. Visit www.himssanalytics.org for

more information.

About The Author Mr. James E. Gaston has 22+ years of healthcare information technology experience which

started at Arkansas Children’s Hospital in medical research and hospital administration,

progressed with Arkansas Blue Cross Blue Shield where he served as the Enterprise EDI

Architect and as a business intelligence leader. Currently, Mr. Gaston is Senior Director of

Clinical and Business Intelligence for HIMSS and HIMSS Analytics, where he facilitates

healthcare clinical and business intelligence related research along with providing expertise in

mobile health and healthcare related information technology.

http://www.himssanalytics.org/


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Appendix A

Ke

y E

lem

en

ts o

r Ex

am

ple

s

Areas of FocusExpectations develop and being reviewed

with preferred SNF FacilitiesExpectations developed in

partnershipwith preferred VNA

Geriatric Model of Care forhigh risk patients

Atrius Health – Hospital Expectations forRelationship Development

(categories all listed below, w illustrative examples)

Screens and admissions seven days per week Care plan documented communicated within48 hours of admission including:

Multidisciplinary case review including: Relationship management- Formal oversight structure with designated contacts on both sides

Quality care as publicly reported Assessment of risk for re-hospitalization

Confirmation of advance directives Care coordination- Coordination of post-discharge f/u with Atrius Health clinician- Jointly address effective and efficient use of ED services- Develop joint readmission reduction strategy

Clear communication with PCP during the SNF stay

Fall risk assessment (tool TBD) Review/accuracy of diagnosis Care management- Use preferred tertiary hospitals, SNF’s, and VNA where appropriate- Medication reconciliation to AH formulary

Discharge planning beginning on the day of SNF admission and including upon discharge:

- Typed, updated medication list- Advance directive information- Referrals to AH preferred providers

Advance care plan forms (HC proxy, MOLST,Advance Directives) transmitted

Review/appropriateness of medications Hospital-based care- Hospitalist program consistent with specified minimum standards- Use AH inpatient consultants where possible

Legible and complete page 1’s transmitted Medication review completed and recommendations communicated to PCP

Social assessment Triple Aim- Quality and Safety metrics sharing and improvement planning

Tracking of patient satisfaction survey results Follow up appt with PCP within 7 days of hosp d/c,if not already scheduled (confirm in EPIC)

Care needs assessment Hospital support for Atrius Health staff- Streamlined credentialing- OR turnaround time and other OR supportive standards

Depression screen (PHQ9) and action plan completed and transmitted

Clinical summary Technology Integration- Identify AH patients at registration- Bi-directional web portal- Timely ED and hospital discharge reports to primary team- Daily census reports

Review of applicable quality measures Marketing- Consistent branding- Shared relationship status with patients

Updated care plan

atrius health pioneer aco clinical intelligence &...

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