Houston Methodist ACO's EHR-integrated quality dashboard boosts quality and shared savings

Value-based care, defined by the National Academy of Medicine as quality over total cost of care, is a cornerstone for healthcare organizations like the Houston Methodist Coordinated Care Accountable Care Organization (ACO). This ACO, responsible for over 52,000 traditional Medicare beneficiaries and partnering with approximately 300 primary care physicians in the greater Houston area, faced challenges in providing real-time feedback on CMS ACO quality performance to physicians.

Dr. Julia D. Andrieni, senior vice president of population health and primary care at Houston Methodist, addressed this by implementing a standardized approach. This involved developing an ACO quality metrics dashboard integrated into the Electronic Health Record (EHR) to identify and address quality gaps during patient visits. By utilizing this dashboard, physicians were able to enhance various aspects of care such as depression screening, fall risk screening, immunizations, and cancer screenings.

To tackle the identification of high-risk patients, predictive analytics tools were integrated into the EHR. These tools, leveraging Medicare claims data, social determinants of health, and real-time EHR data, helped in categorizing patients based on risk scores related to admission, complex care, and advanced illness.

Patient care programs were then tailored according to risk scores, with nursing teams providing targeted interventions for high and rising-risk patients, aiming to prevent unnecessary readmissions and Emergency Department (ED) visits. The overarching goal was to improve quality of care while reducing costs, a fundamental principle of value-based care.

Houston Methodist also implemented comparative analysis using claims data to understand ACO-observed outcomes compared to national benchmarks, providing insights for further improvement. The successful implementation of these strategies resulted in significant improvements in quality metrics over time, with the ACO achieving high percentiles in various CMS Medicare ACO quality metrics.

Lessons learned from this journey emphasized the importance of stakeholder engagement, infrastructure investment, and change management. Dr. Andrieni highlighted the necessity of choosing technology vendors wisely, seeking evidence of outcomes and ongoing support, and fostering true partnerships for sustainable success.