The health information technology

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1 By Emily R. Maxson, Sachin H. Jain, Aaron N. McKethan, Craig Brammer, Melinda Beeuwkes Buntin, Kelly Cronin, Farzad Mostashari, and David Blumenthal Beacon Communities Aim To Use Health Information Technology To Transform The Delivery Of Care communities with already high rates of health IT adoption and provides funding to demonstrate how health IT can improve quality, cost efficiency, and population health. This program will complement and inform the nationwide efforts to spur the adoption and so-called meaningful use of health IT, including the Regional Extension Center and State Health Information Exchange grant programs passed as part of ARRA. The Regional Extension Center program aims to facilitate the adoption and meaningful use of electronic health records among 100,000 primary care providers through practice-level technical assistance. The State Health Information Exchange grant program will promote electronic movement and use of health information between organizations. 3 The Beacon Community Program is a capstone to a broad federal strategy to support new ways of coordinating care, improving patient health, and reducing costs. 2 The program is intended to reflect the enormous number and diversity of practice settings and the unique health care challenges in different communities. It will support the design and testing of the most promising innovations by providers and community leaders at the local or regional level, with support from government, universities, and the private sector. 4 The Beacon program aims to demondoi: /hlthaff HEALTH AFFAIRS 29, NO. 9 (2010): Project HOPE The People-to-People Health Foundation, Inc. ABSTRACT The Beacon Community Program, authorized under the 2009 American Recovery and Reinvestment Act (ARRA), aims to demonstrate the potential for health information technology to enable local improvements in health care quality, cost efficiency, and population health. If successful, these communitywide efforts will yield important lessons that will assist other communities seeking to harness technology to achieve and sustain health care improvements. This paper highlights key programmatic details that reflect the meaningful use of technology in the fifteen Beacon communities. It describes the innovations they propose and provides insight into current and future challenges. The health information technology provisions of the American Recovery and Reinvestment Act (ARRA) of 2009 ushered in a new era in American health care. The law advanced the aspirations voiced by both President Barack Obama and President George W. Bush that all American have access to electronic health records by prescribing billions of dollars in incentive payments to doctors and hospitals that incorporate electronic health records into their daily clinical practices. 1 Although the widespread adoption of electronic health records was an aim of the law, it is not the end goal. Instead, the vision articulated was that meaningful use of health information technology (IT) would lead to improved health outcomes. Carefully implemented, health IT would be a new tool in our arsenal to improve the delivery of health care. 2 Incentives For Demonstrating Reform To provide prominent examples to the nation of how health IT might promote higher-quality and more-efficient care, Congress authorized within the law the Beacon Community Cooperative Agreement Program. The program supports Emily R. Maxson (Emily.Maxson@hhs.gov) is a National Institutes of Health Research Fellow at the Office of the National Coordinator for Health Information Technology (ONC), U.S. Department of Health and Human Services, in Washington, D.C. Sachin H. Jain is special assistant to the national coordinator for health information technology. Aaron N. McKethan is director of the Beacon Community Program at the ONC. Craig Brammer is deputy director of the Beacon Community Program at the ONC. Melinda Beeuwkes Buntin is director of the Office of Economic Analysis and Modeling at the ONC. She is on leave from RAND Health. Kelly Cronin is director of state and community programs at the ONC. Farzad Mostashari is deputy national coordinator for programs and policy at the ONC. David Blumenthal is the national coordinator for health information technology. September :9 Health Affairs 1671

2 strate the promise and potential of these types of collaborations. After a competitive, objective review process that included more than 120 applications, the Office of the National Coordinator for Health Information Technology (ONC) in May 2010 announced $225 million in grants to fifteen Beacon awardees, along with an additional $15 million in evaluation and technical assistance funding to support and learn from these efforts. An additional $30.3 million was made available for two more enrollees in May These communities will have three years to demonstrate how the meaningful use of health IT, as defined under a recently issued federal regulation, 1 can support practical cost, quality, and population health improvements. If successful, the Beacon Community Program will yield practical insights about health IT and identify other steps needed to promote and sustain health care performance improvements that reflect both community and national priorities. In this paper we describe the context for and structure of the Beacon Community Program, highlight key features of the fifteen communities selected, and address critical implementation challenges and questions that lie ahead. The Beacon Community Program With the passage of the American Recovery and Reinvestment Act, and more recently the new national health reform law, the Beacon Community Program has the potential to influence the health of all Americans. As hospitals and eligible providers make the transition to becoming meaningful users of health IT to qualify for substantial Medicare and Medicaid incentive payments, they will need examples and benchmarks toward which to aspire. The Beacon Community Program is expected to provide these examples and benchmarks. Informed by the experiences and insights from previous pilot and demonstration projects, the Beacon Community Program has been structured to use health IT to empower the integration of a range of tools and strategies to achieve targeted improvement goals. Those goals include reducing avoidable hospital readmissions; reducing medical complications among patient populations with complex illnesses; and increasing the use of preventive services. The success of the program will be judged not by technology itself, but by the extent to which patients are receiving better care at a lower overall cost. A Living Laboratory In many respects, Beacon communities may best be viewed as living laboratories and a proving ground for the move to nationwide electronic health records. Given these communities relative sophistication, they are ideal for testing new secondary data use applications, such as performance measurement and payment reforms; consumer engagement strategies, such as personal health records; novel measurement methodologies, including hybrid measures using administrative, clinical, and other data types; and other emerging technology-based innovations. The fifteen Beacon communities represent a sample of a much larger number of communities across the United States that already have advanced strategies in place for health IT, care delivery, performance monitoring and feedback systems, or payment reforms. Although all Beacon communities have above-average electronic health record adoption rates, each has different strengths that will enable the pursuit of improvements in health care quality, efficiency, and population health. Variety Of Communities Selected These particular communities were selected from among America s health IT innovators based on the strength of their proposals, experiences, and accomplishments and on the breadth and depth of community partnerships. Diversity geographic, demographic, and organizational also played a role in the award decision. Finally, each community s commitment to using the Beacon funds to fill gaps in their existing performance improvement practices was an important factor in the award decision. There is no singular model for using health IT to reform health care delivery. Hence, the Beacon program gives communities considerable flexibility to design objectives and strategies tailored to local populations and health care challenges. Geographic, Demographic, And Organizational Diversity The fifteen Beacon communities are located throughout the United States, from rural Stoneville, Mississippi, to sprawling San Diego, California (Exhibit 1). They are located in regions with varying population sizes and diverse demographic characteristics. Among these communities are medically underserved areas, communities with high proportions of racial and ethnic minorities and other vulnerable populations, and regions with unique health challenges (Exhibit 2). Rural communities face particular challenges in implementing health IT because of gaps in broadband coverage, shortages of health professionals, and difficulty accessing hospitals and health care facilities. The rural Beacon communities will test strategies to demonstrate how and 1672 Health Affairs September :9

3 EXHIBIT 1 Geographic Diversity Of The Fifteen Beacon Communities Lead organization Community Services Council of Tulsa Delta Health Alliance Eastern Maine Healthcare System Geisinger Clinic HealthInsight Indiana Health Information Exchange Inland Northwest Health Services Louisiana Public Health Institute Mayo Clinic College of Medicine The Regents of the University of California, San Diego Rhode Island Quality Institute Rocky Mountain Health Plans Southern Piedmont Community Care Plan Inc. University of Hawaii at Hilo Western New York Clinical Information Exchange Location Tulsa, Oklahoma Stoneville, Mississippi Brewer, Maine Danville, Pennsylvania Salt Lake City, Utah Indianapolis, Indiana Spokane, Washington New Orleans, Louisiana Rochester, Minnesota San Diego, California Providence, Rhode Island Grand Junction, Colorado Concord, North Carolina Hilo, Hawaii Buffalo, New York Source Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services. under what conditions they and other communities like them can use health IT to help overcome these challenges. In southeastern Minnesota and the Mississippi Delta, for example, Beacon community leaders will make use of federal broadband grants to expand their digital infrastructure and enable electronic communication between provider locations. In western Washington and eastern Idaho, Inland Northwest Health Services will test a strategy to involve providers in improving diabetes care. The project includes dividing the region surrounding Spokane, Washington, into smaller geographic units and inviting anchor institutions to participate and recruit other regional health care providers. Community Priorities The organizations that led their communities in applying for the Beacon awards included community-based health plans; integrated delivery networks; university-affiliated health systems; and coalitions of stakeholder organizations, including physicians, hospitals, payers, employers, and consumers. Many of these groups had previously convened around other related issues such as health care quality improvement, payment reform, or health information exchange. As part of the process, Beacon community applicants selected specific and measurable performance improvement goals for certain diseases, overall population health, and cost-related measures (Exhibit 3). Applicants focused on common diseases with high associated rates of illness and death. All but one community pro- EXHIBIT 2 Characteristics Of The Fifteen Beacon Communities Category Geographic service area Characteristics 1 predominantly urban community 7 rural communities 7 communities including both urban and rural areas Baseline rate of electronic health record adoption (weighted average) 50% Beacon target populations 6.9 million patients (range: 29,500 1,240,000) Representation of minority populations More than 30% ethnic minority in 4 communities; more than 20% in 8 communities Source Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services. September :9 Health Affairs 1673

4 EXHIBIT 3 Priority Interventions Of The Fifteen Beacon Communities Intervention Health condition targeted for quality improvement Type II diabetes 14 Vascular disease (cerebrovascular and cardiovascular disease, hyperlipidemia) 4 Asthma 4 Hypertension 3 Congestive heart failure 3 Chronic obstructive pulmonary disease (COPD) 2 Cost-efficiency improvement goals Reduce emergency department visits for chronic diseases and ambulatory care sensitive conditions (such as asthma, diabetes, COPD) 12 Reduce preventable hospital readmissions 10 Reduce hospitalizations for ambulatory care sensitive conditions 7 Reduce or eliminate redundant or inappropriate testing, imaging, diagnostic services, referral rates 4 Population health improvement goals Reduce health disparities 8 Improve immunization rates 8 Improve public health surveillance, reporting, or both 4 Improve rates of smoking cessation 2 Improve cancer screening 2 Number of Beacon communities a Source Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services. a Columns do not sum to fifteen. Some communities proposed more than one quality, cost efficiency, or population health improvement goal. posed to focus on diabetes outcome and process measures. Asthma and vascular disease, including hyperlipidemia elevated bad cholesterol and fatty substances in the blood were the next most frequent targets. In the future, new measures must be developed and validated to address a broader spectrum of diseases, performance monitoring, and quality improvements. Beacon communities will also seek to improve care coordination and chronic disease management for ambulatory care sensitive conditions. They hope to accomplish this by using health IT to increase the availability of patient data and by connecting community health care providers, long-term care facilities, hospitals, emergency departments, and patients through health information exchanges. Many Beacon communities plan to employ case managers to follow patients with targeted chronic diseases. The Keystone Beacon Community of Central Pennsylvania led by Geisinger Clinic plans to take advantage of administrative efficiencies already achieved through current health IT systems to increase care coordinators caseloads. Several Beacon communities, including those in Providence, Rhode Island; New Orleans, Louisiana; and San Diego, California, propose to empower patients and family members by increasing access to and usability of their health care information through Web portals, personal health records, and related tools. The use of the patient-centered medical home model is central to several additional projects, including the efforts of the Beacon community in North Carolina s Piedmont region. The specific performance improvement goals and strategies of each community vary. The communities are currently refining their objectives and strategies as they translate their initial proposals into detailed operational plans for implementation, with direction from the Office of the National Coordinator. Yet all of the Beacon demonstration projects aim to not only improve the health of patients with chronic diseases and other conditions, but also to decrease health system costs. By adopting changes to keep patients healthier and decrease the need for acute intervention, Beacon communities will also aim to reduce emergency department visits and hospitalizations for patients with chronic conditions and therefore slow the growth in overall health care spending. Innovations In Health IT To achieve their goals, ten Beacon communities will rely on telemedicine tools, which can include simple telephone calls, messages, or even interactive audiovisual technology, to deliver medical information and services. The Beacon 1674 Health Affairs September :9

5 Several Beacon communities have already integrated health plans and other payers into their consortia. communities serving the regions surrounding Tulsa, Oklahoma, and Hilo, Hawaii, will use telemedicine tools to address severe local shortages of health professionals and specialists. For example, Hawaii County will use cutting-edge videoconferencing technologies to overcome geographic barriers and specialty shortages by providing remote physician visits, thereby reducing the need for patients to fly to Honolulu for specialty care. By electronically connecting local primary care providers and their patients with specialists, these communities expect to increase access to much-needed specialty services and decrease unnecessary referrals. Central Indiana s Beacon community led by the Indiana Health Information Exchange in collaboration with the Regenstrief Institute and other partners will use telemonitoring for high-risk patients after hospital discharge. This community will use remote biometric monitoring combined with telephonic care management using patient-level data from the health information exchange. Similarly, western New York s Beacon community will use telemonitors for high-risk diabetic patients. There, stakeholders will test the deployment of home telemonitoring devices connected to the regional health information exchange. The Beacon community in Bangor, Maine, will use telemedicine to provide more-streamlined care management for elderly patients and those needing long-term and home care. And in southeastern Minnesota, Mayo Clinic will seek to improve asthma care by using a suite of telehealth equipment to connect school systems, hospitals, and public health organizations. The Minnesota Beacon community will deploy a suite of telehealth technologies in schools and public health centers to facilitate collaborative treatment planning and care management between physicians practices and school nurses for children with asthma. It is expected that these and other telemedicine innovations will serve as a test bed for a variety of technology applications that could lead to concrete and sustainable performance improvements. Although the Beacon communities are in different stages with respect to health information exchange, all recognize the importance of a robust infrastructure to connect providers and patients and increase the availability of highquality information. A number of communities will focus on expanding their health information exchange infrastructures and connecting new providers to existing networks, including those in eastern Maine and North Carolina. Pennsylvania s Beacon community plans to add new capabilities to its health information exchange, including giving patients access to test results and prescription information and links with case management software. Indiana s Beacon community will expand the country s largest health information exchange from its current nine counties to forty-one counties and will provide the technical assistance needed to ensure that clinical data submitted by newly participating counties meet already high quality standards. Sustainability And Payment Reform The misalignment of financial incentives in the U.S. health care system namely, provider payment systems based on volume and service intensity rather than quality or value can undermine many of the performance improvement goals that Beacon communities are attempting to achieve. Recognizing this, several communities have already integrated health plans and other payers into their consortia. For example, Rocky Mountain Health Plans which is leading the Colorado Beacon community will provide $750,000 in incentives to physicians both inside and outside of its system. These incentive payments are intended to promote health improvement in this community s entire service area. The Beacon community consortium in central Indiana plans to continue assessing a per member, per month fee to payers for participation in the Quality Health First clinical decisionsupport program, which uses streamlined data collection and aggregation mechanisms to drive point-of-care reminders and enable chronic disease management for improved patient health outcomes. Private insurers WellPoint and UnitedHealthcare, along with Medicare, are already participating in this clinical decision-support program. Many other Beacon communities pledged to strengthen existing ties with similar organizations that deal with quality and to use September :9 Health Affairs 1675

6 improvements in data collection and integrity as a foundation for future third-party payer initiatives, such as implementation of accountable care organizations, bundled payment programs, or advanced health IT enabled medical homes. The Beacon communities pursuing this strategy include the one in Maine, the Better Living Utilizing Electronic Systems (BLUES) Beacon in the Mississippi Delta, and HealthInsight in Salt Lake City, Utah. Importantly, as part of the technical assistance and strategic guidance that Beacon communities will receive during the program, all participants will work to develop detailed strategic plans to ensure that their specific performance improvement goals are supported by the payment system. Each Beacon community is expected to engage directly with local and national payers and purchasers and with other partners, including state and federal governments. Certain communities will use the Beacon process as a glide path toward implementation and testing of more-sophisticated forms of provider reimbursement aimed at ensuring that performance improvements are sustained for years to come. These more-sophisticated reimbursements include developing accountable care organizations, experimenting with bundled payments, and pursuing more-advanced medical home models with payments aligned, at least to some degree, with actual performance on improving care and lowering overall costs. Several Beacon communities already have experience in this regard and can provide insights to others about integrating payments to align with performance improvement goals and measures. 5 For example, Geisinger Clinic participated in the Medicare Physician Group Practice (PGP) demonstration project for the past several years. This project granted shared savings bonuses to practices that improved the quality of care. The North Carolina Community Care Program a subset of which is a Beacon community and the Indianapolis Health Information Exchange participate in the Medicare Healthcare Quality Demonstration. These existing Medicare demonstration programs also provide bonuses when providers achieve specific performance improvements on cost and quality measures. The Beacon Community Program will work toward implementing these and other kinds of payment innovations to ensure that quality and efficiency improvements are maintained after the program ends. Moving Forward Although each Beacon community is advanced relative to other communities in one or more Leaders from Beacon communities are working together to identify strategies that emphasize the role of health IT as a foundation for reform. areas of health IT, care delivery, or payment reform, most have had neither the opportunity nor the resources to deploy their practices in a more robust way. In the coming months, Beacon community awardees will work together and with the Office of the National Coordinator to advance their community-specific models based on common core principles. Each Beacon community will complete a ninety-day process that involves clear articulation of specific aims, performance measures, technology infrastructure with measureable outputs, workflow redesign approaches, and, ultimately, ongoing business models. In time, this business model and sustainability plan will be based largely on anticipated payment reform and value-based purchasing opportunities. Community-level innovations such as pay-for-performance pilots and the establishment of accountable care organizations will demonstrate whether the performance improvement gains enabled by health IT are sustainable through provider reimbursement strategies that support quality and efficiency improvement instead of volume and service intensity. Increased use of electronic health records and health information exchanges are vitally important goals. However, Beacon communities emphasize that these technologies are all in service of larger population objectives related to cost, quality, and population health. Leaders from Beacon communities are now working together to identify common performance measures and other cross-cutting strategies that emphasize the role of health IT as a foundation for delivery system, quality improvement, and payment reforms. During the first phase of the Beacon program, leaders from each community will prioritize technology investments that will lead to measurable improvements in the coming 1676 Health Affairs September :9

7 years. These leaders envision the Beacon Community Program as a larger organism and not merely a collection of fifteen communities as they begin to develop a coherent approach for interacting with communities outside this select group. These fifteen communities, and the two additional Beacon community grantees that will be selected later this year, are not the only forwardlooking U.S. health care markets. The Beacon communities join a growing family of established, regionally focused reform initiatives, including the Robert Wood Johnson Foundation s Aligning Forces for Quality 6 and the Agency for Healthcare Research and Quality s Chartered Value Exchange. Together, this community of communities is the steward of a large and growing knowledge base about local, market-specific health care reform. Tapping this knowledge base demonstrating that regional reform is achievable, sustainable, and replicable will be important in the coming years as the country seeks to execute a national reform agenda where success is in many ways dependent upon local leadership, strategy, and infrastructure. Also well poised to join this broader community are many of the Beacon applicants that were not ultimately selected to receive funding. The application process necessitated an unprecedented level of communitywide collaboration, commitment, and strategy development. These efforts may stimulate communities to leverage newly formed strategic partnerships and use other resources to pursue their goals. The Beacon communities are well positioned to demonstrate the potential of health IT to transform the U.S. health care system. Time and experience will reveal their successes and limitations, all of which will increase the general body of knowledge and enable communities across the country to apply the lessons to their own efforts to achieve health IT enabled improvements in quality, cost efficiency, and population health. This paper solely reflects the views of the authors and does not represent any official policies or positions of the U.S. Department of Health and Human Services. NOTES 1 Blumenthal D, Tavenner M. The meaningful use regulation for electronic health records. N Engl J Med Jul 13. E-pub ahead of print. See 2 Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff (Millwood). 2010;29(6): Blumenthal D. Launching HITECH. N Engl J Med. 2010;362(5): McKethan A, Shepard M, Kocot SL, Brennan N, Morrison M, Nguyen N. Improving quality and value in the U.S. health care system [Internet]. Washington (DC): Bipartisan Policy Center; 2009 Aug [cited 2010 Aug 2]. Available from: bipartisanpolicy.org/library/report/ improving-quality-and-value-ushealth-care-system 5 Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008;27(5): Painter MW, Lavizzo-Mourey R. Aligning Forces for Quality: a program to improve health and health care in communities across the United States. Health Aff (Millwood). 2008;27(5): September :9 Health Affairs 1677