Mind the gap: Bridging care coordination, IT infrastructure no easy feat

While the Centers for Medicare & Medicaid Services has made significant progress in implementing its new physician payment scheme, it lacks the IT infrastructure to collect the data allowed by the Medicare Access and CHIP Reauthorization Act (MACRA) final rule, a recent report by the U.S. Department of Health and Human Services' Office of Inspector General concludes.

Early on, IT resources were trained on having a public-facing website ready when the final rule on MACRA’s Quality Payment Program (QPP) was published. Work on a QPP service desk is also underway. Still needed, according to the 40-page report, is backend infrastructure to support critical QPP processes — receiving and validating physician-submitted data, providing performance feedback, determining Merit-based Incentive Payment System scores, and adjusting payments.

Addressing that vulnerability in the year ahead will be critical to QPP’s continued implementation, OIG notes. But it’s no easy task.

“Building and testing the extensive IT systems necessary to support critical QPP operations will require significant and sustained effort over the forthcoming year,” the report says. “In the past, CMS has sometimes experienced delays and complications related to major IT initiatives, such as those required for the continued operation of Medicare Part D and HealthCare.gov. If the complex systems underlying the QPP are not operational on schedule, the program will struggle to meet its goal of improving value and quality.”

In response to the report, CMS said it is working to improve backend IT infrastructure. Regarding the QPP website, for instance, the agency said it “has adopted an agile IT development methodology to test components of the system during the development process rather than waiting to test until the system is fully built.”

Farzad Mostashari, CEO and co-founder of Aledade and former National Coordinator for Health IT, tweeted shortly after release of the report that CMS’ technology shortfalls are not new. “We wanted to-but couldn’t-create a nationwide directory of Direct addresses, as a by-product of the MU attestation process in 2013,” he wrote.


“The way payment incentives are structured isn’t optimal, a by-product of inflexible backend IT systems.”

Farzad Mostashari

CEO and Co-Founder, Aledade


These challenges aren’t unique to CMS, Mostashari adds. 

Structural changes are needed

Fully implementing QPP is going to require “major, major structural changes” for hospitals and health systems, Joshua Newman, CMO and general manager for healthcare and life sciences at Salesforce, told Healthcare Dive. “The first is getting data that might live outside the walls of the healthcare organization," Newman says. "The second is how do they work with other organizations that they might not be part of. And the third is what supports the process inside the company or organization.”

Organizations can start out by putting in place systems or apps that allow them to send out surveys and get results back from patients, so that they can build longitudinal data, he says.

Next is to build capacity for sharing information with other organizations. Newman recommends using a cloud-based system that can adapt and incorporate different kinds of data without organizations having to worry about the connections, integration, and data cleansing.


“There are obviously some problems with patient identification but I’ve heard of a bunch of good startups recently and companies that are trying to tackle that problem.”

Joshua Newman

CMO and General Manager for healthcare and life sciences, Salesforce


Finally, organizations need systems that are adaptable to changes. “I think that over time we’re going to see more and more collaboration, training and workflow processes happening on technologies that might not start off super sophisticated but can change over time” as new requirements come along, such as checklists and patient safety measures, Newman says. “We really don’t have a good place to put that right now in organizations that only have EMR.”

Identifying and tackling barriers

Building complex systems that can handle a wide range of clinical and administrative tasks, however, can be challenging for organizations with scarce resources and capital. While it’s easier to invest in something that solves an immediate problem, what’s needed are solutions that have legs and the ability to grow over time.

“There are hundreds of companies dedicated to diabetic reminders or blood pressure reminders or cancer screening reminders,” says Newman. “The question is can that system also be a repository for the MRI data that comes from the MRI center down the street or can it receive information about medications or receive information about mental health screenings?”

One way hospitals can increase their workflow capacity is by embracing social networks, says John Halamka, chief information officer at Boston’s Beth Israel Deaconess Medical Center. “BIDMC has already created a prototype of groupware documentation and we should complete our next generation inpatient documentation solution by mid 2017,” he writes in a recent blog. “Part of that work incorporates open source secure texting as part of the medical record.”

The hospital is also testing Google’s G-Suite as a vehicle for storing and sharing data and communicating using only a browser. “Our vision is to eventually eliminate the need for a managed desktop,” Halamka says.

He notes that mobile apps include a number of backend services such as APIs and BOTs. “An app that a patient might use to schedule an appointment online might include a BOT to engage in a dialog about time of day preferences and the severity of illness,” Halamka writes. For example, BIDMC has a bedside drug dispenser that tracks patient-reported pain ratings and patient-administered painkillers. The captured data will help physicians understand how to manage pain with less reliance on narcotics.

Like Newman, Halamka also sees the cloud as the answer for much of today’s infrastructure challenges. “Our experience suggests that IT FTEs are unlikely to be increased,” he writes.


“The only way to enhance innovation and customer service is to move the work that can be moved to the cloud, freeing up time of existing IT FTEs for new work.”

John Halamka

Chief Information Officer, Beth Israel Deaconess Medical Center


BIDMC currently has contracts with Amazon Web Services for application hosting, storage and analytics, with Google for G-Suite and Dell/NTTData for community hospital EMR hosting, Halamka notes. To protect itself in the event of privacy breaches, the hospital acquired a third-party cyber liability policy.

Another challenge for IT infrastructure is how to handle bundled payments. For an integrated network, that’s not so difficult. But hospitals that send money to other organizations need to ensure the quality of services provided and that people actually did the work, and document outcomes over time. No hospitals have systems in place to do that currently, Newman says.

The other issue is whether hospitals can deal with bundled payments and keep their doors open if they don’t know the ultimate cost of bundled procedures. Hospitals today don’t have the systems to do that work, the systems to get paid or the systems to predict how much revenue is coming in, he adds.

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