Wednesday, February 13, 2013

From HITECH to Accountable Care: A Student and Workforce Development Program Success Story

This year's State of the Union address by President Barack Obama noted that controlling the costs of healthcare, particularly of Medicare and Medicaid, is a critical element of addressing the government's debt problem, especially in the long run. A key element of this approach, as the President noted, will be new models of care delivery. As he stated, "medical bills shouldn’t be based on the number of tests ordered or days spent in the hospital; they should be based on the quality of care that our seniors receive." One of the key elements for operationalizing this approach is the development of accountable care organizations (ACOs) [1], whose goals are to achieve Dr. Donald Berwick's "triple aim" of improved health, improved healthcare delivery, and reduced cost [2].

To this end, President Obama invited Oregon's Governor, Dr. John Kitzhaber, to be present at his address. Dr. Kitzhaber's presence acknowledged his leadership and innovation in healthcare reform that is taking place in Oregon. With help from the Obama Administration, Oregon is revamping its entire Medicaid program under a new brand of ACOs known as Coordinated Care Organizations (CCOs). The Oregon CCOs will provide value-driven coordinated care for Oregon Medicaid patients in pursuit of the "triple aim." As with all ACOs, managing information, including that beyond the electronic health record (EHR), will be critical for the success of Oregon's CCOs. Indeed, a recent post by Dr. John Halamka posited that "ACO = HIE + analytics," a shorthand way of stating that ACOs (and CCOs) will require robust health information exchange (HIE) and data analytics.

The importance of health information technology (HIT) to accountable care was recognized in the Health Information Technology for Clinical and Economic Health (HITECH) Act when it was passed in 2009 [3]. Indeed, one of the original roles for HITECH was to serve as a "down payment" for healthcare reform [4].

I am pleased to report of one recent instance, small but significant, where HITECH funding has indeed resulted in an outcome that is helping healthcare reform and accountable care. It is the story of two individuals who pursued our University-Based Training (UBT) program and have both been hired by Health Share of Oregon, the CCO for the Portland, Oregon tri-county region.

Isolde Knaap worked in the State of Oregon's Department of Human Services for over 20 years in various positions as a data analyst/system developer/research analyst. During that time, she built a wealth of experience managing data and systems in public health and child welfare. Aiming to advance her skills and career more into the HIT realm, she applied and was accepted into the Oregon Health & Science University (OHSU) Graduate Certificate Program, funded by the UBT training grant. Her previous educational background include a Bachelor of Arts in Modern Languages with a secondary teaching certificate.

After graduation from the program, Isolde was hired by Health Share of Oregon as a Senior IT Project Manager. Like all CCOs, Health Share Oregon is tasked to improve health outcomes and reduce health cost through collaboration with previously disparate health care providers. Isolde's position will help align IT processes so that the care delivery transformation activities of Health Share Oregon achieve the triple-aim goals while also achieving administrative simplification.

One of the courses in her program of study Isolde found most useful was Introduction to Standards and Interoperability. This gave her an appreciation for the challenges of health information exchange, a critical function for CCOs who share financial accountability for providing care for their patients. She stated that she was asked in various interviews what she knew about EHRs, and replied that she could confidently state that she had taken the courses, Clinical Information Systems and Clinical Information Systems Laboratory, and later served as a teaching assistant in the latter. She also purposefully chose a practicum with a local Veteran's Administration hospital to get exposure to their VistA EHR (which was used in the Clinical Information Systems Laboratory course).

Charles Sorgie is another UBT graduate who has been hired by Health Share of Oregon, serving as a Senior IT Business Analyst. Charles has a long history of work in the IT field as a software developer, designer, and architect. He had no experience in the healthcare domain but had developed a documentation management system to support electronic design automation that was subsequently adopted by the aerospace industry to manage their maintenance documentation. In addition, he was involved more recently in the process modeling and enterprise modeling fields, which led him to become interested in ways to organize and model the processes, resources, and work products involved in complex business interactions. His educational experience was a Master of Science in Computer Science.

In his position with Health Share of Oregon, Charles is involved in the gathering of stakeholder requirements and acting as a coordinator and liaison between those stakeholders and the IT teams tasked with the deployment of solutions to satisfy those requirements. He notes that the OHSU UBT program proved him a basic understanding of the challenges in the support of clinical processes, their privacy and security requirements, their workflow, and the standards used to support that workflow (e.g., HL7). It also gave him a background to the basic terminology used (e.g., personal health information, or PHI) as well as the challenges surrounding the business processes that support those clinical processes. All of this helps him be more productive in his current position.

Both Isolde and Charles report to Daniel Dean, the Chief Information Officer (CIO) of Health Share of Oregon. Their connection to Mr. Dean was made possible by another resource provided by our UBT grant, which is Virginia Lankes, who is the Career Development Specialist that the grant enabled us to hire. The connections Ms. Lankes had nurtured with Mr. Dean made him aware of our two students as they were completing their studies.

Isolde and Charles are thus examples of how the UBT program has developed the HIT workforce and how the HITECH program is contributing to healthcare reform. The two of them also provide a refreshing counterexample to the common adage that one must have a clinical background to succeed in biomedical and health informatics. As I have written, the work of informatics is shifting from implementation to data, and their experience and expertise in using data seems to have played an important role in their new positions.

The story of Isolde and Charles provide more examples of how the UBT funding of our educational program has helped individuals advance their careers and added jobs to the economy. Their experiences build on the successful outcomes that other students in the program have had, as I documented in 2011 and 2012.

Postscript: Sure enough, the day after this posting, an article appeared in the New England Journal of Medicine, describing the Oregon CCO program [5]. It is a well-written overview and freely available, so I will add this postscript to provide this additional information.


1. Berwick, D. (2011). Making good on ACOs' promise--the final rule for the Medicare shared savings program. New England Journal of Medicine 365: 1753-1756.
2. Berwick, D., T. Nolan and J. Whittington (2008). The triple aim: care, health, and cost. Health Affairs 27: 759-769.
3. Blumenthal, D. (2010). Launching HITECH. New England Journal of Medicine 362: 382-385.
4. Blumenthal, D. (2009). Stimulating the adoption of health information technology. New England Journal of Medicine 360: 1477-1479.
5. Stecker, E. (2013). The Oregon ACO experiment — bold design, challenging execution. New England Journal of Medicine Epub ahead of print.

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