HPI633 Assignment 6

eGEMs (Generating Evidence & Methods to improve patient outcomes) Volume 2 Issue 3 Lessons from the Field: Health IT-Enabled Community-Based Transformation

Article 2

7-21-2014

The Keys to Governance and Stakeholder Engagement: The Southeast Michigan Beacon Community Case Study Terrisca R . Des Jardins Independent Consultant ( formerly Director for the Southeast Michigan Beacon Community), [email protected]

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Recommended Citation Des Jardins, Terrisca R . (2014) "The Keys to Governance and Stakeholder Engagement: The Southeast Michigan Beacon Community Case Study," eGEMs (Generating Evidence & Methods to improve patient outcomes): Vol. 2: Iss. 3, Article 2. DOI: http://dx.doi.org/10.13063/2327-9214.1068 Available at: http://repository.academyhealth.org/egems/vol2/iss3/2

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Introduction The need for guidance on community governance structures is

growing. Communities of providers and other relevant stakehold-

ers are coming together for population health-related initiatives

such as Accountable Care Organizations,1 community-based health

information exchanges (HIEs),2 organized systems of care,3 com-

munity-level quality improvement initiatives, and similar deliv-

ery-system reform pilots. These population health related initiatives

oftentimes include improved population health, quality, patient ex-

perience, and efficiency goals. At the same time, they seek to reduce

cost and duplication of services. These ambitious goals call for data

sharing at a minimum and, if needed, data sharing in combination

with community-level data warehouse and clinical data repository

(CDR) infrastructure. This technical infrastructure allows consol-

idation and secure storage of patient data across data sources, and

data use for patient treatment and population-level analytics.

Community-level governance implications exist when an infra-

structure for data sharing and storage across disparate providers

and organizations is put into place. In turn, there needs to be

a method to address community governance and stakeholder

engagement at two levels: a macro-level (i.e., community-level)

executive leadership and participation, and a micro-level (i.e., com-

munity-based) intervention oversight and leadership.

The Southeast Michigan Beacon Community (SEMBC) in Wayne

County, Michigan is one of 17 federally funded efforts through the

Department of Health and Human Services that conducted work

on the following areas of focus over a 3-year pilot period:

• Building and strengthening health IT (HIT) infrastructure and

exchange capabilities, positioning each community to pursue a

new level of sustainable health care quality and efficiency over

the coming years;

• Translating investments in HIT to measureable improvements

in cost, quality, and population health (as seen through an initial

but scalable focus area, e.g., diabetes, asthma, heart disease, etc.),

and;

• Developing innovative approaches to performance measure-

ment, technology, and care delivery to accelerate evidence gener-

ation for new approaches.4

The urban SEMBC includes Detroit, Highland Park, Hamtramck,

Dearborn, and Dearborn Heights. Economic woes and population

flight, including movement of many health care providers to the

suburbs,5 have led to Wayne County (where these cities are located)

being ranked last in Michigan in The County Rankings & Roadmaps Program.6 Diabetes—selected as the area of focus for work during the pilot period—prevalence in Detroit is estimated to be as high as

16 percent, and the proportion of people who are on Medicaid or

uninsured in SEMBC is almost twice as high as the rest of Michigan.7

The Keys to Governance and Stakeholder Engagement: The Southeast Michigan Beacon Community Case Study

Terrisca R. Des Jardins, MHSAi

iIndependent Consultant, formerly of Southeast Michigan Beacon Community

Abstract Community-based health information exchanges (HIEs) and efforts to consolidate and house data are growing, given the advent

of Accountable Care Organizations (ACOs) under the Affordable Care Act and other similar population health focused initiatives.

The Southeast Michigan Beacon Community (SEMBC) can be looked to as one case study that offers lessons learned, insights

on challenges faced and accompanying workarounds related to governance and stakeholder engagement. The SEMBC case

study employs an established Data Warehouse Governance Framework to identify and explain the necessary governance and

stakeholder engagement components, particularly as they relate to community-wide data sharing and data warehouses or

repositories. Perhaps the biggest lesson learned through the SEMBC experience is that community-based work is hard. It requires

a great deal of community leadership, collaboration and resources. SEMBC found that organizational structure and guiding

principles needed to be continually revisited and nurtured in order to build the relationships and trust needed among stakeholder

organizations. SEMBC also found that risks and risk mitigation tactics presented challenges and opportunities at the outset and

through the duration of the three year pilot period. Other communities across the country embarking on similar efforts need to

consider realistic expectations about community data sharing infrastructures and the accompanying and necessary governance

and stakeholder engagement fundamentals.

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SEMBC and a subset of other Beacon Communities employed

data warehouses and community-level, clinical data repositories

as part of their strategy to carry out the aforementioned nation-

al aims. SEMBC can be looked to as one case study that offers

lessons learned, insights on challenges faced, and accompanying

workarounds over the 3-year pilot period related to governance

and stakeholder engagement. The lessons learned through

SEMBC are from real-world, “on the ground” pilot efforts across

multiple interventions and community stakeholders. SEMBC’s

experiences could prove beneficial to others across the country

embarking on similar community-level initiatives.

Case Study Framework and Methodology Elliott et al. conducted a literature review of data warehouse

governance (DWG) programs and found existing guidance for

the health care industry was sparse.8 Of the 15 articles included

in their final article list, only 3 related to health care settings.

The others focused on commercial settings. Elliott et al. point to

David Walker as defining DWG as “the model an organization

will use to ensure optimal use and re- use of the data warehouse

and enforcement of corporate policies (e.g. business design,

technical design and application security) and ultimately de-

rive value for money.”9 Elliott et al. offer a framework, derived

from The Data Governance Institute (DGI) Data Governance

Framework, that this case study employs to describe the SEMBC

experience, with nine components for organizations to consider

on DWG including:

1. Mission, vision, purpose;

2. Strategy, goals, and objectives with metrics for each objective;

3. Guiding principles;

4. DWG organizational structure and position within the greater

organization;

5. Policies and processes for governing the data warehouse;

6. Users’ training, support and engagement;

7. Technical operations (data model, definitions, quality, metadata);

8. Security, access, privacy, risk and compliance; and

9. Communications plan for stakeholders, users and leadership.

While SEMBC did not embark on its pilot efforts with direct

knowledge of the DWG framework, what SEMBC needed to

address over the pilot period is consistent with the components

included in the framework, given SEMBC’s inclusion of a com-

munity-level HIE and in particular a CDR as part of its work

during the pilot period. Further, what makes SEMBC unique is

the DWG framework being applied to an entire health care com-

munity working together rather than applied to a single health

care setting or entity.

Methodology This case study relies largely on direct observation and experience,

given that the author served as Director for the SEMBC during

the pilot period, from February 28, 2011 through December 31,

2013. The author also reviewed SEMBC documents, including:

final and periodic qualitative and quantitative reports to the Office

of the National Coordinator for Health Information Technology

(ONC), the SEMBC website, governing board and committee

documents and decisions, meeting minutes, lessons learned

captured from SEMBC participants and contractors, among other

programmatic records.

SEMBC and the Chronic Care Model Before moving forward with a description of SEMBC’s efforts

across each of the above DWG framework components, it is

important to note that interventions and the overall technical

approach were both based on the identified need to provide better

population and individual-level health management for adults

with diabetes. Additionally, SEMBC stakeholders recognized that

any technical approach and intervention pursued also needed

to be scalable and applicable to other disease states and general

patient care. The Chronic Care Model10 (CCM), also referred to

as the “Care Model” has been deployed throughout the SEMBC

community by multiple stakeholder organizations (e.g., payers,

health systems and hospitals, and large physician organizations)

as the community embraces delivery system change. SEMBC’s

approach was very consistent with the CCM, as SEMBC deployed

most of the CCM’s elements during the pilot period.

The focus of this paper is on DWG and SEMBC’s governance and

stakeholder engagement experiences. However, the CCM was also

foundational to clinical interventions developed. The CCM and

the DWG framework offer a comprehensive and complementary

approach for communities seeking change in the delivery system

that builds off of a technical foundation. The CCM encourages a

multipronged approach to caring for communities, including the

reorganization of health care, self-management support, decision

support, delivery system design, clinical information systems, and

community resources and policies as areas for needed interven-

tion. The DWG framework offers guidelines on elements import-

ant to governance programs for data warehouse efforts. Coupled

together, the CCM and DWG may offer a comprehensive picture

of the full spectrum of work areas needed to pursue communi-

ty-based transformation.

Mission, Vision and Purpose SEMBC stakeholders defined a mission—or clear, common pur-

pose—and a vision for collaborative work as part of the original

application development and submittal to the federal government

to become a Beacon Community. This was accomplished by

convening ad hoc planning groups during the proposal writing

phase. There was a clinical workgroup that comprised community

physician leaders; and also a technical workgroup of local chief

information officers, chief medical information officers, and other

technical experts. The groups met separately initially to divide the

work, given the short turnaround required for proposal submis-

sion. However, they also combined forces after initial plans were

fleshed out. These workgroups crafted the overall mission, vision,

and purpose and also developed tentative work plans to guide

the work upon award, taking into account both the current and

desired future state.

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There were conflicting views, both pre- and postaward, on wheth-

er or not a community-level clinical data repository was need-

ed to accomplish the work. Ultimately, consensus was reached

approximately 10 months after the funding award. To accomplish

the population-level analytics needed for a community picture

of care, the consensus was that some central housing of data,

through a community-level CDR, was desired. Stakeholders felt

that current federated technology approaches could not provide

the type of community-based analytics sought.

To achieve this consensus, SEMBC convened an additional Ad

Hoc IT Workgroup—comprising board members, IT experts,

and clinicians—for approximately 3 months to review various

technology options, facilitate additional questions and answers

with potential vendors, and develop a final recommendation to

pursue a dual HIE vendor solution for governing board approval.

(Following vendor contract execution, and after nearly 7 months

of pursuing a dual HIE vendor solution, SEMBC reversed course

to follow a one-vendor HIE approach, given challenges related to

tight timelines for implementation.)

Table 1. Initial Key Governance Dates

September 2010: February 2011:

March 2011: May 2011: June 2011:

July 2011:

January 2012:

ONC awards SEMBC federal funding SEMHA convenes SEMBC Governing Board Staff hiring process commences Ad Hoc IT Committee begins meeting HIT-Enabled Clinical Transformation Interventions Implementation begins Ad Hoc IT Committee Technology Strategy Recommendation approved by SEMBC Board HIE Vendor Contracts executed

SEMBC’s mission and vision point to accomplishing something

larger than the implementation of technology itself. While key

to accomplishing the ultimate mission and goals, technology is a

means and not an end. SEMBC’s mission during the pilot peri-

od was to improve diabetes mellitus (DM) care and associated

outcomes in SEMBC’s medically underserved and disadvantaged

community—while reducing costs. Given the emphasis on chronic

disease, at least initially, the CCM provided guidance for potential

interventions to support improvements in diabetes care. SEMBC’s

vision statement is that the Detroit area’s patient-centric, electron-

ically connected system of care coordination delivers the best pos-

sible health care. This system is designed to optimize each health

care related encounter and promote the attainment of optimal

health outcomes. As part of the initial planning period, SEMBC

stakeholders also developed a series of “big hairy audacious goals,”

(BHAGs) that served as longer-term “reach” goals or aspirations.

Table 2. SEMBC Mission and Vision

SEMBC Mission Statement: To improve diabetes mellitus (DM) care and associated outcomes in SEMBC’s medically underserved and disadvantaged community—while reducing costs.

SEMBC Vision Statement: The Detroit area’s patient-centric, electroni- cally connected system of care coordination delivers the best possible health care. This system is designed to optimize each health care relat- ed encounter and promote the attainment of optimal health outcomes.

SEMBC’s work engaged hundreds of organizations across

interventions and committee governance roles. Although indi-

vidual stakeholder organizational representatives changed over

the course of the pilot period, there was not much movement in

participating organizations. Consistent stakeholder participa-

tion at an organizational level was important for the consistent

application of the mission and vision over the pilot period. When

organizations were added to address various pilot needs, or

when there was individual representative turnover for an existing

stakeholder, SEMBC staff provided an orientation including the

mission, vision, and common purpose.

Strategy, Goals, and Objectives with Metrics

for Each Objective As a Beacon Community, SEMBC needed to focus on federal aims

(as stated earlier) and local strategies, goals, and objectives within

those overarching aims. SEMBC deployed a series of strategically

integrated interventions across ambulatory care sites (Federally

Qualified Health Centers, private primary care practices, etc.)

and hospital emergency departments, and also community-fac-

ing interventions, too many to detail within this case study (See

Appendix A for Intervention/Work Area, Objectives, Metrics, and

Results Summary table). Each intervention had a specific set of

subgoals to achieve, strategies and objectives to accomplish each

goal, and defined metrics and data sources for tracking and evalu-

ation. Equally important, for each area of work, SEMBC identi-

fied risks and risk mitigation tactics, and requisite timelines and

stakeholder and staff assignments for planning, implementation,

continuous evaluation, and ongoing improvement.

Risk mitigation, particularly related to deployment of commu-

nity-level data sharing and aggregation, required a substantial

amount of time over the pilot period. The SEMBC clinical trans-

formation workgroup identified anticipated risks and mitigation

tactics for each intervention as part of an initial risk assessment.

SEMBC staff and contractors were primarily responsible for actual

risk mitigation during the pilot period. Examples are discussed in

the Lessons Learned section later in this article.

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Guiding Principles SEMBC stakeholders developed a set of guiding principles for

governance generally, and specifically for data sharing and the

data repository deployed. For example, relative to governance

generally, stakeholders agreed to a set of principles that included

placing community goals before individual organizational goals

when deploying SEMBC work. Stakeholders initially agreed to

enter into Beacon activities with a noncompetitive spirit. Spe-

cific to the data repository, this meant that health care providers

would “not compete on data,” as all the major health system

CEOs committed to, and would share data for a community-level

data repository. This meant supporting the consolidation of data

through the real-time exchange of data and storing data for future

information sharing.

Table 3. SEMBC Governing Board Roles, Responsibil- ities, and Operating Principles (Abbreviated List)

General Roles and Responsibilities: 1. Provide overall program oversight and guidance; 2. Promote Beacon Project within the SEM community; 3. Promote Beacon Project within your own organization; and 4. Provide support to the Beacon project appropriate to your organiza-

tion’s role in project.

Operating Principles: 1. We will operate in an open, honest, and transparent environment. 2. We will create good (not perfect) plans. 3. We will focus on achieving the project objectives. 4. We will focus on execution and delivery.

6. We will respect our team members and give everyone an opportuni- ty to express their opinion without fear of ridicule or embarrassment.

7. We will engage in positive discussion (and debate) to resolve issues. 8. People will keep the commitments they make - in the timeframe

promised. 9. We will work to limit scope creep and budget creep. 10. We will trust each other to complete the work. 11. We will document our work, our communications and our achieve-

ments. 12. We will celebrate our successes. 13. Decisions will be made in a timely fashion. 14. Decisions may be revisited with the approval of the majority of the

Board, but will not be routinely second guessed. 15. We will run this project in the best interest of the community at large

and not according to any individual or corporate agenda.

The original set of guiding principles did not change; however, the

board co-chairs periodically revisited or highlighted particular

guiding principles during board meetings. This revisiting of prin-

ciples served as a reminder to member organizations, for example,

about what to do in cases where there were potential conflicts of

interest and placing community goals before organizational goals.

The guiding principles were challenged at many times over the

course of the pilot, given a very competitive marketplace, uncer-

tainties in the direction of federal policy, changes in institutional

leadership at a local level, internal organizational priorities for

electronic health record (EHR) system installations and conver-

sions, and other competing priorities. Given these challenges,

and also the federal timelines, there were points during the pilot

period where SEMBC exhausted all potential efforts in reaching

consensus among partners. Alternatively, SEMBC moved certain

work forward with a “collaborative of the willing.” All stakeholder

organizations remained “at the table” through the duration of the

work from a governance perspective. All stakeholders participated

at some level across at least one intervention. However, not all

stakeholders participated at the same level as originally envi-

sioned.

DWG Organizational Structure and Leadership Given sensitivities related to data sharing and “ownership” of

the process and data under the federally supported pilot, orga-

nizational structure was one of the most important elements for

SEMBC’s experiences related to governance. It required time to

nurture the necessary relationships and trust across the com-

munity of stakeholders in order to move work forward. SEMBC

had to address several layers of organizational structure at both

the macro- and micro-levels: lead agency and fiduciary (macro),

community-level governance (macro), and intervention-level

oversight (micro).

First, given SEMBC’s multi-stakeholder composition, a lead

agency and fiduciary was needed to organize the work, man-

age staff on a day-to-day basis, and to interface with the federal

government. Given the multi-stakeholder nature of the work, as

well as the very tight timelines for Beacon Communities, it was

necessary for SEMBC to identify an existing, experienced non-

profit organization to serve as lead agency and fiduciary for the

community in order to jump-start efforts. Doing so eliminated the

need for pilot efforts to incorporate independently, which would

have required additional agreements among stakeholders. SEMBC

and the federal government leveraged the Southeastern Michi-

gan Health Association (SEMHA), with an over 60-year history

in the community, to serve this role. Based on the experience in

southeast Michigan, criteria for selecting a lead agency for other

communities to consider include: neutrality, community longev-

ity, prior and on-going relationships with community stakehold-

ers, community trust, a mission consistent with the activity at

hand, experience managing federal grants, and the ability to fulfill

activities related to staffing, human resources, contracting, and

financial management.

Leadership SEMBC also convened an executive board, a group of nearly 30

leaders representing public and private institutions. The board

was co-chaired by a respected physician leader and an executive

from the regional Chamber of Commerce, and was charged to

provide directional decision making and oversight for the pilot

work. There was no executive committee structure. However,

given the large number of board members, there were circum-

stances where additional deliberation was needed (e.g., during the

technical vendor contracting phase) for decision making. When

these occasions arose, SEMBC staff organized telephonic board

meetings as well as an opportunity for board members to meet

on-site with SEMBC staff for additional information, review and

guidance. Given the community goals and requisite data sharing,

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membership of the SEMBC Executive Board included physician

organizations and health systems, Federally Qualified Health Cen-

ters (FQHCs), and other private and hospital-affiliated ambulato-

ry care providers, payers (both public, e.g., State of Michigan and

Centers for Medicare and Medicaid Services (CMS), and private),

employers, consumer organizations, quality improvement organi-

zations, and universities, among others. Some board organizations

represented their individual organization (e.g., hospital, physician

organization); others represented groups (e.g., regional chamber

representing employers, Voices of Detroit Initiative representing

FQHCs). SEMBC’s lead agency, SEMHA, worked with local orga-

nizations and the federal program office to identify the member

organizations to serve on the board during the pilot period.

Organizational representatives needed to be leaders within their

respective organizations. They also had to be in a position to make

commitments on behalf of their organizations, and adhere to an

established set of board member expectations related to their roles

and responsibilities and ethical considerations relative to SEMBC.

For example, if they served in another capacity that presented

a potential conflict, disclosure and, if needed, resolution of the

conflict, were required.

The executive board created numerous workgroups and subcom-

mittees reflecting the membership required to carry out pilot

work. These groups met on a regular basis and set the course

for planning and activation of SEMBC’s HIT- and HIE-enabled

clinical interventions. Meeting frequency varied by workgroup

and subcommittee, and was more frequent during planning

and implementation. Reporting to the executive board, SEMBC

workgroups and subcommittees established during the pilot

period included: HIE-Enabled Clinical Transformation (originally

two separate workgroups to spread the planning and facilitate

a quicker start to activities), several subcommittees for specific

interventions, Privacy and Security, Evaluation and Measurement,

Sustainability, and Communications. SEMBC facilitated regular

physician and office staff user groups that served as a forum to

share early lessons learned and provide input on refinement for

activities. SEMBC staff also facilitated monthly leadership calls

with the board co-chairs, as well as periodic planning meetings

with all the workgroup co-chairs.

Two noteworthy issues encountered both at a board level and also

at the workgroup and committee level include: (1) the importance

of striking an appropriate balance between the technical experts,

clinicians, legal and operational leaders; and (2) the necessity

of having designated staff and contractors to manage and con-

duct the work. SEMBC encountered issues on both fronts at the

outset and through the duration of the pilot period. Striking the

right balance between individual representatives, given different

areas of expertise, opinions and beliefs about data sharing, and

orientation and understanding of how to best approach a given

intervention was a challenge. And, although SEMBC’s work was

community driven and relied on stakeholder participation, it was

important to have a set of experienced, full-time staff members

and contractors who could navigate stakeholder relationships and

provide day-to-day management for the work. In some cases, giv-

en the lack of resources, certain participants (e.g., FQHCs, quality

improvement organizations, university evaluators, ambulatory

care clinics, and others) were contracted to participate across

interventions; and some were provided funding to offset the costs

of participation, technology, and staffing.

Toward the end of the federally supported pilot period, and as

the activities and organization itself transitioned to the next steps

and changing areas of focus, SEMBC also encountered the need

for a flexible organizational structure. That is, organizations not

originally involved needed to serve a larger role, and the actual

structure is now morphing into something new and not support-

ed by federal pilot funding. SEMBC’s original board no longer

exists, given the conclusion of the pilot period in September, 2013.

SEMBC’s participating physician organizations, FQHCs, and in-

terested health systems are in the process of forming “The Beacon

Cooperative,” which is anticipated to transition current Beacon

governance and technology to a newly formed and independent

nonprofit organization. In the meantime, SEMBC’s lead agency,

SEMHA, continues to assist in facilitating the transition and also

holds the HIE designation from the Michigan Health Information

Network. However, transition challenges are emerging related to

sustainable funding sources, differing organizational technology

and exchange priorities, and competing marketplace demands

and incentive programs.

Policies and Processes for Governing the Data

Warehouse and Security, Access, Privacy,

Risk, and Compliance SEMBC found enough overlap in relevant stakeholder partici-

pants to combine the necessary governance activity on privacy

and security, and policies and procedures for the data repository,

under one umbrella. This was accomplished through the Privacy

and Security Workgroup reporting to the executive board and

chaired by an attorney and a technologist (a chief information

officer from a large physician organization). The workgroup

comprised both legal and nonlegal health system, hospital, and

physician representation, as well as representation from local

universities.

SEMBC’s main objectives were to ensure that its HIE and accom-

panying data repository was a trusted Health Insurance Porta-

bility and Accountability Act (HIPAA) compliant entity and to

safeguard against potential breaches. Activities included develop-

ing necessary policies and procedures governing use and protec-

tion of data, and HIPAA and Health Information Technology for

Economic and Clinical Health (HITECH) Act protocols; monitor-

ing policies, procedures and protocols for needed enhancements;

developing and executing data sharing agreements, interven-

tion-level memorandums of understanding and other required

agreements; exercising due diligence in making sure SEMBC’s

vendors and participants are HIPAA compliant; and conducting

training, among other activities.

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SEMBC staff secured sample agreements, policies and procedures,

and other documentation from communities with similar techni-

cal strategies to serve as templates for SEMBC development. Staff

first edited template documents to be consistent with local work.

Staff then circulated the draft documents to workgroup members

for their individual comments, combined all comments into a

master document, convened the workgroup to review suggested

edits, and then forwarded final documents (when necessary) to

SEMBC attorneys for review. The SEMBC Executive Board would

then grant final approval. The ability to secure sample documents

from other communities, coupled with local stakeholder commit-

ment to rigorously review drafts internally first, helped accelerate

the timeline for development across all needed documents.

Given that the overall technical approach and data use princi-

ples were established by SEMBC leadership through a consensus

building process, the workgroup faced few challenges related to

specific legal verbiage in contracts and policies and procedures.

Users’ Training, Support, and Engagement Training, support, and engagement were needed across all SEM-

BC interventions to address technological-, quality and process

improvement-, and clinical-intervention implementation needs.

SEMBC’s clinical and technical workgroups identified this level of

support as necessary for successful interventions. SEMBC’s lead

agency allocated necessary budgets, from a governance standpoint.

SEMBC facilitated these activities through practice coordinators

who regularly interfaced with participants at each intervention

site to provide necessary training and support with intervention

roll-out and ongoing activity. Practice coordinators had combined

expertise in health care quality improvement, technology, and

process improvement, among other areas. SEMBC also found it

important to engage both physician and practice champions (both

clinical and administrative) to support deployment. Training

largely occurred on-site and was ongoing through the duration

of the pilot period. The level of training dedicated to a particular

practice or other intervention site was determined based on need.

There were occasional off-site in-person and telephonic training

opportunities provided to participants. One example was an early

morning (so as not to interfere with business hours) training

session on capturing race, ethnicity, and primary language from

patients. Additionally, as mentioned previously, SEMBC also facil-

itated regular physician and office staff user groups to share early

lessons learned and to iterate on interventions.

Technical Operations (Data Model, Defini-

tions, Quality, Metadata) Where this activity overlapped with privacy and security ef-

forts (e.g., auditing and monitoring of the data repository, data

flow, and maintenance), certain technical operation activities

fell under the privacy and security domain. Where the activities

addressed data quality, measure definitions, metadata, and other

similar areas, SEMBC leveraged its Evaluation and Measurement

Workgroup to provide oversight. Part of this decision was related

to function, but part of it was because SEMBC’s HIE and data

repository were not live at the outset of the pilot period. This

necessitated having to retrieve other data sources for operations,

intervention assessment, and evaluation. These data sources

included claims data from private payers, Medicare and Medicaid,

clinical data from health systems, lab data from a lab vendor that

aggregates data across community labs, and clinical data pulled

manually from EHRs. The committee used standard National

Quality Forum (NQF)-endorsed Healthcare Effectiveness Data

and Information Set (HEDIS) measures, and accompanying mea-

sure definitions, to calculate baseline and quarterly measures for

the community level and at the individual intervention site.

Given that SEMBC was able to pursue an alternative plan for

needed data from the outset, SEMBC was able to quickly establish

a measurement baseline. SEMBC then subsequently collected data

from established sources on a quarterly basis. The Evaluation and

Measurement Workgroup was able to secure initial data-source

commitments quickly by reaching consensus that these initial

data sets were only to be used for measurement purposes and that

comparative information would be blinded if shown publicly.

In parallel to ongoing data collection and measurement through

the evaluation process, significant technical work moved forward

during the pilot period. The technical work included: identifi-

cation of the overall technical strategy (community-level HIE

plus CDR), development of the HIE vendor request for proposal,

facilitation of a bid and contracting process, and development

and implementation of the HIE and data repository. The technical

implementation efforts during the pilot period focused on the

deployment of an Integrating the Healthcare Enterprise (IHE)

and HIPAA-compliant master patient index (MPI), integration

and testing of data sources and EHRs into the HIE and CDR, and

roll-out of initial use cases related to public health reporting and

population health management. By the end of the pilot, SEMBC

had over 100,000 consolidated patient lives recorded in the CDR,

which was doubling in size every 2 months.

Communications Plan for Stakeholders,

Users, and Leadership From a governance and community buy-in perspective, clear

communications were important in keeping all stakeholders up to

date. SEMBC employed a full-time communications and mar-

keting director during the pilot period. The director developed

a recognizable brand for SEMBC, using a consistent logo, color

scheme, and graphics. SEMBC shared regular, very transparent,

and consistent communications on progress to establish a trusted

brand across the community. The director also developed com-

munications that emphasized alignment of SEMBC work with

existing community priorities and incentive programs.

Perhaps most importantly, efforts were deployed to demystify

HIT and HIE and the community-level clinical data repository.

HIT and HIE can be concepts that are difficult to understand and

articulate. Having a communications expert on hand to translate

“IT-speak” and clinical terminology for different audiences (phy-

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sicians, consumers, and executives) was important to gaining ear-

ly and ongoing support. SEMBC produced multiple, easy-to-un-

derstand brochures and brief one-pagers that explained concepts

in plain language for clinical and nonclinical audiences. SEMBC

practice coordinators and technical staff used the materials as part

of their ongoing work with SEMBC participants.

Over the course of the pilot, communications about “early wins,”

and the ability to show early results, to the extent possible, were

also important to building stakeholder buy-in and momentum for

the work. SEMBC also developed executive board dashboards for

reporting at board meetings, other regular reporting for the ONC

and SEMBC workgroups, quarterly newsletters for all interested

partners, and videos to help highlight specific interventions. SEM-

BC also participated in other dissemination activities including

journal articles, HIT and HIE roadmaps, and local and national

presentations.

Lessons Learned Perhaps the biggest lesson learned through the SEMBC experi-

ence is that this work is hard, particularly within the context of

a federally funded, time-limited pilot period. While many of the

other Beacon Communities had existing HIE and CDR infra-

structure to leverage, SEMBC’s work included design of, contract-

ing vendors for and implementing the HIE and CDR within the

pilot period. SEMBC’s work required a great deal of community

leadership, collaboration, and resources.

Other communities across the country embarking on similar

efforts need to consider realistic expectations about how much

time is required to build a community-level data infrastructure

and deploy multiple interventions leveraging the infrastructure or

other HIT assets available. Shared decision-making around HIE

strategy, vendor bid and contracting processes, and commence-

ment of the technical implementation required approximately

9 more months than originally anticipated as part of the 3-year

pilot. (Most Beacon communities had nearly 3½ years, however,

SEMBC was one of two communities granted funds approxi-

mately 6 months after the initial award.) Establishing a trusted

community leadership and governance structure, and continuing

to cultivate stakeholder relationships, sets the foundation for

work. At the same time, if consensus is not able to be achieved, it

may be necessary to consider approaching pieces of the work with

a “collaborative of the willing,” with the hopes that others will join

SEMBC’s efforts later when they are ready. Finally, other commu-

nities embarking on similar work may benefit from considering

the following challenges and opportunities SEMBC faced.

Challenges and Opportunities SEMBC encountered many challenges and expected and unex-

pected risks including: absence of an HIE and CDR at the outset,

lack of stakeholder consensus across certain areas, limitations in

technical capabilities, and competing stakeholder demands. How-

ever, challenges also presented opportunities and other lessons

learned that are described in more detail below.

General Approach to Risks and Risk Mitigation Risks, expected and actual, and risk mitigation, particularly relat-

ed to deployment of community-level data sharing and aggrega-

tion, required a substantial amount of time over the pilot period.

The SEMBC clinical transformation workgroup identified poten-

tial challenges and risks, as well as mitigation tactics, at the outset

(and through the duration) of the initiative. The entire SEMBC

team approached the work as many of the clinics approached their

interventions, with a “Plan, Do, Study, Act,” rapid-cycle quality

improvement mindset. It is difficult to approximate the amount

of time staff and contractors devoted to risk mitigation, but time

spent became a part of anticipated daily work with clinics, other

intervention sites, and technical vendors.

First, the workgroup identified potential participant readiness and

attrition risks. To address these risks, the clinical transformation

workgroup recommended that pilot participants have an EHR and

patient registry in place at the outset of planned interventions.

Having a system already in place, even if the system was not

being optimally or meaningfully used, was perceived as a signal

that the practice or provider was ready (or more ready) to engage

than were those without a system. Additionally, the workgroup

recommended that staff overrecruit so that the interventions had

more participants than were required to cover any attrition over

the duration of the initiative. SEMBC did experience attrition due

to retirement, death, and relocation, with very few opting out due

to lack of interest.

Addressing Technical Capability Challenges Technical capabilities and the limitations faced, both from a user

standpoint and also relative to vendor offerings, presented chal-

lenges over the duration of the pilot. These challenges included:

EHR interoperability, lack of data standards (data content and

transport), propriety programs, cumbersome reporting tools,

and lack of easy-to-understand vendor training materials, among

others. To address user-related issues, SEMBC deployed practice

coordinators and technical staff to assist with practice-level data

pulls and other technological needs.

SEMBC was also actively involved with the ONC Beacon-EHR

Vendor Affinity Group, comprised of ONC representatives, sev-

eral Beacon Communities, and EHR vendors, to collaborate on a

mutually agreed upon set of data and interoperability standards in

alignment with Meaningful Use (MU) Stage 2 requirements. In a

short period, the Affinity Group along with participating Beacon

Communities were able to assist the EHR vendor community

(and selected HIE vendors) to better focus and prioritize their

development efforts of evolving content standards (C32/C83/

CCDA) and transport standards (IHE and Direct) in real world

environments. One of the goals of this work was to not only assist

vendors to achieve MU stage 2 certification more rapidly, but in

a manner that provided end users with more meaningful options

for exchange that could be held up by the ONC as models for

other vendors to emulate (repeatable and scalable).

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However, despite some progress on standards development, SEM-

BC continued to struggle with issues related to vendor standards

and interoperability, particularly given the tight timelines for the

Beacon Communities. Given competing marketplace demands

and priorities, very few participating EHR vendors were able to

meet agreed upon timelines for standards development, testing,

and deployment. Another associated challenge was that of provid-

ers not upgrading to new versions of the EHR software when EHR

vendors were ready.

Addressing Competing Demands with Local and Na-

tional Programming Alignment Another important and very real risk identified was one of

competing demands across participants, given various public and

private incentive programs and multiple demonstration projects

throughout the community. Competing demands included: mul-

tiple measure sets for regular incentive reporting, multiple care

management and patient navigation interventions (leading one

stakeholder to quip that a care manager was needed to coordinate

the care managers available to an individual patient), and meeting

the needs of underserved populations. SEMBC also experienced

very tight timelines, given the federal pilot period. SEMBC inter-

ventions, to the extent possible, were developed in alignment with

the local payer and federal meaningful use incentive program

offerings. Additionally, SEMBC staff met regularly with leadership

from other initiatives to align efforts and pursue common work

where possible.

Despite efforts toward alignment, SEMBC was not able to resolve

all competing demands. For example, given the tight timelines

the Beacon Communities faced, SEMBC was not able to meet the

overall meaningful use11 community goals before the end of the

Beacon program. The CMS offers an incentive program to Medi-

care and Medicaid providers who meaningfully use EHRs toward

improved patient care. The ONC required all Beacon Communi-

ties to conduct activities around meaningful use and to set a goal

for each community to bring 60 percent of its eligible providers

through the first stage of meaningful use. One of the challenges is

that the total number of physicians targeted by the ONC included

the entire defined geography, regardless of whether SEMBC was

directly working with the physician on a SEMBC intervention.

Addressing Additional Meaningful Use (MU) Goal

Challenges The other significant challenge around the meaningful use work

was that the federal incentive program timelines allowed provid-

ers more time than the local SEMBC timelines. This issue was

further exacerbated since most of the SEMBC providers qualified

for incentives under the Medicaid program, which allows a more

phased in approach to capturing incentives. So, while SEMBC

was asking clinic participants to meaningfully use their systems

as part of the SEMBC intervention work, CMS provided initial

incentive payment for the purchase and installation of a system

and not the use of it.

Despite these challenges, SEMBC in partnership with MPRO

(Michigan’s Quality Improvement Organization and one of the

lead organizations for meaningful use work in Michigan) made

significant progress in assisting providers to engage and use tech-

nology meaningfully. All SEMBC participating providers, a subset

of the total MU-eligible providers, had installed and were using

EHRs and patient registries by the end of the program period. Of

the 593 eligible professionals in the SEMBC catchment area, 20

percent had achieved Stage 1 MU as of September 2013, and an

additional 41 percent were in the process of doing so.

See Table 4 for a summary of the key challenges, lessons learned,

potential solutions, and opportunities.

Table 4. Challenges and Lessons Learned, and Potential Solutions and Opportunities

Key Challenge or Lesson Learned Potential Solution and Opportunity

Absence of HIE and CDR at outset of pilot. Reconceptualize activities during the project to move forward interventions in parallel. Identify other mechanisms and data sources to evaluate efforts.

Stakeholder consensus not always possible across work areas/interventions.

Communicate participant expectations at front end of work. Continually nurture stakeholder gover-

phase in interventions as needed, given competing priorities. Overrecruit for participation.

Expected and unexpected risks. Conduct risk assessment and identify risk mitigation tactics at outset, and periodically review. Approach overall work, not just interventions, with a “Plan, Do, Study Act” rapid-cycle quality improvement mindset.

Technical capability limitations relative to both users and vendors.

Deploy practice coordinators to assist with technological needs. Participate in standards devel- opment activities. Participate in EHR vendor pilots. Use a single set of resources across practices rather than have each practice attempt to develop their own internal HIT/HIE resource.

Competing demands across stakeholders and participants.

Align efforts with other community and federal initiatives and incentive programs to the extent possible. Meet with community leaders to identify ways to better align work across community to reduce “noise” faced by providers.

“Boots on the Ground” are just as important as technology itself.

“Boots on the ground” are essential in engaging and coordinating care of urban/inner-city patients who may be challenged by issues related to social and economic determinants of health. Tech-

practice coordinators, and others are needed for work to succeed.

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Conclusions The SEMBC experience provides lessons learned and insights to

other similar community-based initiatives, particularly those that

include data sharing in combination with stored data through data

warehouses or repositories. Elliott et al. offers a DWG framework

with nine components needed for health care settings to consider.

In SEMBC’s case, the DWG framework applied to an entire health

care community working together rather than to a single health

care setting. SEMBC found it necessary to address all the DWG

framework components in order to pursue its work. SEMBC also

found that organizational structure and guiding principles needed

to be continually revisited and nurtured in order to build the

relationships and trust needed among stakeholder organizations

pursuing common community work and goals set forth.

Acknowledgements This work was supported by AcademyHealth. The author wishes

to thank Alison Rein and Abigail Schachter.

References 1. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Pay-

ment/ACO/

2. http://www.healthit.gov/HIE

3. A local initiative similar to an ACO, and supported by Blue-

CrossBlueShield of Michigan. http://www.bcbsm.com/pdf/

OSC-Value-Partnerships-flier.pdf

4. http://www.healthit.gov/policy-researchers-implementers/

beacon-community-program

5. http://www.mpca.net/displaycommon.cfm?an=1&subarti-

clenbr=72#.UsB2DPRDuSo

6. http://www.countyhealthrankings.org/

7. Fussman C. Health Indicators and Risk Estimates by Commu-

nity Health Assessment Regions & Local Health Departments.

Selected Tables, Michigan Behavioral Risk Factor Survey,

2008 - 2010 Combined. Michigan Department of Community

Health, 2011. Available at: http://www.michigan.gov/docu-

ments/mdch/2008-2010_MiBRFS_Reg__LHD_Tables_FI-

NAL_351398_7.pdf

8. Elliott, TE; Holmes JH.; Davidson, AJ; La Chance, P; Nelson,

AF.; and Steiner, JF. (2013) “Data Warehouse Governance

Programs in Health Care Settings: A Literature Review and a

Call to Action.” eGEMs (Generating Evidence and Methods to

improve patient outcomes): Vol. 1: Article 15.

9. Walker, DM. Data Warehouse Governance. Data management

and warehousing 2007. www.datamgmt.com.

10. Stellefson, M; Dipnarine, K; Stopka, C. (2013) “The Chronic

Care Model and Diabetes Management in US Primary Care

Settings: A Systematic Review.” Prev Chronic Dis: 10:120180

11. http://www.cms.gov/Regulations-and-Guidance/Legislation/

EHRIncentivePrograms/Meaningful_Use.html

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Appendix A. Interventions/Work Areas, Objectives, Metrics, and Results Summary

Intervention/Work Area Objective Metrics Results

Clinical Decision Support (CDS) • Alert for A1c • Alert for Patient Health

Navigator (PHN) based on elevated A1c

• Alert/reminder for blood pressure

• Diabetic reminders • LDL documentation • Reminder for foot exam

Primary care clinician/site imple- ments CDS within EHR, registry, and other with assistance of SEMBC practice coordinator. CDS implementation to assist with better quality care and pa- tient outcome. Goal established at outset was to realize at least a 5% improvement for each measure.

Healthcare Effectiveness Data and Information Set (HEDIS) diabetic measures: • A1c testing • LDL testing • Eye exam • Foot exam • BP<140/90 • A1c value <8.0 • A1c value >9.0

Baseline followed by quarterly measure calculation. Additional measures were tracked at a com- munity level.

125 physicians engaged with approx. 180,000 total patient population. 18,000+ patients with diabetes. Achieved from 5% to nearly 20% improvement on all but one targeted measure, with eye exam being the one measure with no movement. *

Patient Education • Body mass index (BMI)

brochure/pamphlets • Diabetic educator/class • Nutrition education • Documentation education

with encounter form • Salt-free diet education and

handout

Primary care clinician and site implements patient education supports with assistance of SEMBC practice coordinator, patient navigator, and other community resources. Educa- tion to assist with better patient engagement and outcome.

HEDIS diabetic measures as listed above.

See above.

Other Health Information Technology (HIT) • Diabetic Action Plan • HIT report to capture

hypertensive patients and medication review

Primary care clinician and site implements HIT strategies with assistance of SEMBC practice coordinator. HIT to assist with improving quality of care and patient outcome.

HEDIS diabetic measures as listed above.

See above.

Quarterly metric and data report review

Primary care clinician and site pulls and reviews quarterly metrics and data report for review, and targeted quality im- provement with assistance from SEMBC practice coordinators. Review to assist with improv- ing quality of care and patient outcome.

HEDIS diabetic measures as listed above.

See above.

Tools • Hemoglobin A1c Poster • Create colored DM checklist

for all measures • Diabetic Action Plan • Diabetic questionnaire

showing date of last event • Text4health

Primary care clinician and site uses tools developed and pro- vided by SEMBC. Tools to assist with improving quality of care and patient outcome.

HEDIS diabetic measures as listed above. For Text4health: participant experience survey.

See above. Also regarding text4health: Over 1,000 patients completed enrollment and ac-

satisfaction in the service and improvements across multiple behavior change indicators).

change; monitor A1c and LDL actively

• Tracking log for outside tests

documentation

socks and shoes

exams

and physician

Primary care clinician and site works with SEMBC practice coordinator to review and

assist with improving quality of care and patient outcome.

HEDIS diabetic measures as listed above.

See above.

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Appendix A. Interventions/Work Areas, Objectives, Metrics, and Results Summary (cont’d)

Intervention/Work Area Objective Metrics Results

Patient Health Navigator (PHN)

Primary care clinician and site work with SEMBC PHN to identify and refer high risk patients for PHN intervention. PHN to assist with patient engagement, com- pliance with treatment plan, goal setting and removal of barriers to care, among other areas.

HEDIS diabetic measures as listed above. Pre-, immediate post, and 6 months post patient survey. Ad- ditional patient experience survey conducted. Metrics included pa- tient engagement, patient reported health status and use of services, patient knowledge of disease, and other.

See above. Over 2,200 referrals, with 50% -

cant improvement in: medication adherence, readiness to change (healthy food choices, being physically active, checking blood sugar, keeping appointments, and other).

Diabetic screening at emergency department (ED)

EDs work with SEMBC to conduct diabetic screening at ED, with con- nection to diabetic educators and

- cation of patients with or at risk of diabetes and connection to regular source of care for better manage- ment and reduction of ED use.

Number of patients screened. Percent of diabetics, prediabetics, referral to PHN, ED use.

previously unknown diabetics or prediabetics. 57% reduction in ED visits for patients who engaged with PHN and diabetic education and connection with primary care. 33% reduction in ED visits for patients who were told they were diabetic and did not engage with additional SEMBC assistance offered.

Health Information Exchange (HIE)and Clinical Data Repository (CDR)

Planning, vendor bid, and con- tracting process, implementation of HIE and CDR to facilitate information exchange among participants and better population health management through use of CDR. Conducted in parallel with HIT-supported interventions and work areas described above.

HIE participants. EHR and data source integrations. Number of patients captured within CDR. Survey of practices and physicians regarding knowledge, attitudes, beliefs and perceptions re: HIT and HIE over time. Baseline and postsurvey.

HIE and CDR was live, with implementation in process by end of pilot period. Participation from entire safety net provider community, including all FQHCs in Wayne County. Orga- nizations representing 4,500 physicians, one large health system, labs signed on to engage over time. 102,000 lives in CDR and doubling approximately every 2 months at end of pilot period. Recognized as state-designated HIE. Ten major data integrations complete, with many more in progress, at end of pilot period. Provider perceptions about EHRs and registry, comfort level with technology, and belief that HIE will help practice made positive directional

as sample size too small. Also, documented perceived growing issue and obstacle with lack of internal practice and clinic project manage- ment related to HIE participation. Early use cases implemented for public health reporting,

patients for follow-up.

Meaningful Use (MU) Primary care clinician and site work with SEMBC practice coor- dinators to pursue MU to assist with improving quality of care and patient outcome. ONC goal for SEMBC was to assist 60% of community-eligible providers (not just those providers SEMBC was actively working with) to achieve MU by end of pilot period.

HEDIS diabetic measures as listed above. MU metrics for physicians in process.

All 125 SEMBC participating providers, a subset of the total MU-eligible providers, had installed and were using EHRs and patient registries by the end of the program period. Of the 593 eligible professionals in the SEMBC catchment area, 20% had achieved Stage 1 MU as of September 2013, and an additional 41% were in the process of doing so.

Community events SEMBC hosted or participated in community outreach events to facilitate awareness of SEMBC activities. Selected events also assisted in diabetic screening and referral to primary care.

Not actively measured. SEMBC hosted or participated in over 70 com- munity outreach events during pilot period.

Remote diabetic retinal exams SEMBC worked with 4 clinics at end of pilot period to implement remote diabetic retinal exams to address issue that eye exam mea- sure remained unchanged.

Too late in pilot period to implement measurement.

Positive anecdotal feedback from practices on improved patient compliance through point of care service.

Note: This table does not document work associated with establishing the community governance structure, evaluation and measurement process, or communications as these areas are documented within the case study narrative.

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