her general comments: 
 
 
 
U.S. Department of Health and Human Services 
Office of Inspector General 
 
Using Health IT for 
Care Coordination: 
Insights From Six 
Medicare 
Accountable Care 
Organizations 
 
OEI-01-16-00180 
May 2019 
Daniel R. Levinson 
 
Inspector General 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
May 2019 
Office  of Inspector General 
OEI-01-16-00180 
 
 
Using Health IT for Care Coordination: 
Why OIG Did This Review 
Insights From Six Medicare Accountable Care 
This evaluation provides insights into 
how select ACOs have used health IT 
Organizations 
tools to better coordinate care for 
their patients.  It can help ACOs 
Key Takeaway 
What OIG Found 
anticipate challenges they might face, 
The six accountable care 
Overall, health information technology  and it can help the Centers for 
organizations we visited 
(health IT) tools have enabled the six  Medicare & Medicaid Services (CMS) 
have used health IT tools to 
Medicare accountable care organizations  and the Office of the National 
better coordinate care for 
(ACOs) we visited to better coordinate  Coordinator for Health IT (ONC) assist 
their patients.  However, the 
patient care.  (An ACO is a network of  ACOs in overcoming those challenges.  
promise of seamless 
doctors, hospitals, or other healthcare  Health IT has significantly enhanced 
integration and coordination 
providers that come together voluntarily to  providers opportunities to coordinate 
across providers and care 
coordinate high-quality care for their  patient care across healthcare 
settings has not yet been 
patients.)  ACOs that used a single  settings.  Medicare patients often 
realized.   
electronic health record (EHR) system across  have chronic medical conditions that 
their provider networks were able to share  require care from multiple providers.  
data in real time, enhancing providers ability to coordinate care.  A small  Care coordination helps ensure that 
number of ACOs had access to robust health information exchanges, which  patients needs for health services are 
give ACOs access to patient data even when patients see providers outside the  met over time and across multiple 
ACOs networks.  Most of the ACOs we visited used data analytics to inform  encounters and settings.  CMS has 
their care coordination by identifying and grouping patients according to the  identified care coordination as 
potential severity and cost of their health conditions.   integral to achieving better care, 
improved health, and lower costs.  
However, the ACOs we visited still face challenges in these areas.  ACOs that 
CMS has implemented various 
used multiple EHR systems had to rely on other means to share data among 
payment models for promoting these 
providers, either using additional health IT tools or relying on phone calls and 
goals in Medicare, including models 
faxes.  Although EHRs are intended to streamline, coordinate, and improve 
that use ACOs.  
care, ACOs report that EHRs can also be burdensome and frustrating for 
providers.  ACOs also faced challenges from physician burnout due to the 
How OIG Did This Review 
workload of managing EHRs.  Most of the ACOs had access to health 
We based this data brief on interviews 
information exchanges with little or incomplete data, making it difficult to 
we conducted during site visits to six 
coordinate care when patients saw providers outside the ACOs networks.  Few 
Medicare ACOs (four were Next 
of the ACOs use analytics to customize care to an individual patients needs.  
Generation ACOs and two 
Finally, few ACOs offer health IT tools to patients, other than online portals to 
participated in the Medicare Shared 
their EHRs. 
Savings Program).  We considered the 
What OIG Concludes  following factors when selecting 
ACOs: their performance on a quality 
The ACOs we visited have used health IT to aid in care coordination in a variety 
measure focused on care coordination 
of ways.  However, the full potential of health IT has not been realized.  ACOs 
and patient safety, a minimum of  
vary in the extent to which they can rely on health IT tools, in some cases 
3 years of experience as a Medicare 
because those tools cannot reach all providers involved in a patients care, or 
ACO, geographic variation, and 
because the tools lack the necessary information that ACOs need.  Achieving 
recommendations from CMS and 
the interoperability needed for seamless care coordination places burdens on 
ONC.  We discussed with ACO 
ACOs to either invest in a single EHR system or use other methods, such as 
administrative staff and providers how 
non-health IT means, to communicate health information. 
ACOs use health IT to coordinate care 
Full report can be found at oig.hhs.gov/oei/reports/oei-01-16-00180.asp  for their patients.  Table of Contents 
 
BACKGROUND  1 
Methodology  7 
   
A Brief Profile of the Accountable Care Organizations We Visited  9 
Coordinating at the Point of Care: Electronic Health Records  10 
Coordinating at the Point of Care: Health Information Exchanges  13 
Coordinating at the Population Level: Analytics  15 
Coordinating at the Patient Level: Patients Use of Health IT  18 
   
CONCLUSION  21 
   
ACKNOWLEDGMENTS  23  Background 
Medicare patients often have chronic medical conditions that require care 
from multiple providers.  In fact, more than half of Americans older than 
65 require significant medical or functional support.  This care comes at 
a considerable cost to the program, even as quality outcomes may not 
reach desired goals.1  As a result, alternative payment approaches to 
healthcare have emerged in which providers have financial incentives to 
identify risky patients and coordinate their care before those patients 
complex needs result in even higher costs.  Accountable Care Organizations 
(ACOs) are one type of this alternative approach.  An ACO is a network of 
doctors, hospitals, or other healthcare providers that come together 
voluntarily to coordinate high-quality care for their patients and be 
accountable for the total cost and quality of the care provided.  
 
Care Coordination  According to the Centers for Medicare & Medicaid Services (CMS), 
coordinated care aims to ensure that patients get the right care at the right 
time, while avoiding unnecessary duplication of services and preventing 
medical errors.2  The goal of care coordination is to facilitate the 
appropriate and efficient delivery of healthcare services both within and 
across systems of care.3  The Department of Health and Human Services 
(HHS or the Department) is focused on transforming the healthcare system 
from one that pays for procedures and sickness to one that pays for 
outcomes and health.  Two focus areas of the shift to value-based care are 
maximizing the promise of health information technology (health IT), 
including through promoting interoperability and removing barriers to care 
coordination.4 
 
 
1 Bruce Chernof and Mark McClellan, Form Follows Funding:  Opportunities for Advancing 
Outcomes for Complex Care Patients Using Alternative Payment Methods, Health Affairs 
Blog, August 10, 2018.  Accessed at 
https://www.healthaffairs.org/do/10.1377/hblog20180803.928422/full/ on November 1, 2018. 
2 CMS, Coordinating Your Care.  Accessed at https://www.medicare.gov/manage-your-
health/coordinating-your-care/coordinating-your-care.html on November 1, 2018. 
3 Agency for Healthcare Research and Quality, Care Coordination Atlas, ch. 2.  Accessed at 
https://www.ahrq.gov/professionals/prevention-chronic-
care/improve/coordination/atlas2014/chapter2.html on November 1, 2018. 
4 HHS, Secretary Priorities.  Accessed at  
              https://www.hhs.gov/about/leadership/secretary/priorities/index.html#value-based- 
              healthcare on April 19, 2019. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations   1 
OEI-01-16-00180 
  Health Information  Health IT refers to the hardware, software, and network infrastructure that  
enables patient data to be recorded and 
Technology 
shared on an ongoing basis among multiple 
Health IT is the computer 
providers and across care settings.5  Providers 
hardware and software 
can enhance care coordination with health IT 
that facilitates the 
tools to create data and facilitate data 
storage, retrieval, sharing, 
exchange.  Health IT can help reduce 
and use of health care 
duplicative or unnecessary testing, provide 
information, data, and 
clinicians with comprehensive information for 
knowledge for 
decisionmaking, and prevent medical errors.  It 
communication and 
can be particularly useful for beneficiaries who 
decisionmaking. 
see multiple specialists and transition among 
care settings within a provider network, as all the providers involved can 
have up-to-date information as the patient transitions among these 
different settings.6   
Electronic Health Records (EHRs) are real-time, patient-centered records 
that contain information about medical history, diagnoses, medications, 
immunization dates, allergies, radiology images, and lab and test results.  
EHRs may also include medication lists and treatment plans.7  In 2011, CMS 
implemented regulations for the Medicare and Medicaid EHR Incentive 
Programs, now known as the Promoting Interoperability Programs, to 
encourage eligible providers and hospitals to adopt, implement and 
meaningfully use certified EHR technology.8  Between May 2011 and July 
2018, CMS paid incentive payments totaling nearly $25 billion to providers 
through this program.9  EHRs are part of a broader suite of health IT 
applications used to coordinate health management.  Below, see a glossary 
of health IT terms that this report uses.  
   
 
5 Office of the National Coordinator for Health IT (ONC), Health IT TermsGlossary of 
Selected Terms Related to Health IT.  Accessed at https://www.healthit.gov/topic/health-it-
basics/glossary on February 19, 2019.  See 42 U.S.C.  300jj(5) for the complete statutory 
definition of health IT. 
6 ONC, Benefits of EHRs.  Accessed at https://www.healthit.gov/topic/health-it-
basics/benefits-ehrs on November 1, 2018.  
7 ONC, What is An Electronic Health Record (EHR)?  Accessed at 
https://www.healthit.gov/faq/what-electronic-health-record-ehr on November 1, 2018. 
8 75 Fed. Reg. 44313 (July 28, 2010). The Health Information Technology for Economic and  
Clinical Health Act (HITECH Act), enacted as part of the American Recovery and Reinvestment 
Act of 2009, P.L. No. 111-5, established the Medicare and Medicaid EHR incentive programs 
to promote the adoption of EHRs and to improve healthcare quality, safety, and efficiency 
through the promotion of health IT and electronic health information exchange. 
9 CMS, Data and Program Reports.  Accessed at https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/DataAndReports.html on November 1, 2018. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  2 
OEI-01-16-00180   
Glossary of Health IT Terms That This Report Uses 
Electronic health record (EHR): a digital health record that generally includes medical history, lab results, 
charts, and treatment plans.  
Health information exchange (HIE): a network that provides the capability to electronically move clinical 
information among disparate healthcare information systems, and maintain the meaning of the 
information being exchanged. 
Population-level analytic tools: software applications that allow organizations to identify trends and assess 
risk using large data sets made up of their patient populations health information.    
Patient-facing tools: health IT tools that patients can interact with directly, such as Internet-based portals 
to their EHRs.   
 
 
 
Other types of health IT include networks over which health data are 
exchanged.  HIEs are a common example of this kind of network.  HIEs are 
networks that allow healthcare providers to 
securely access, update, and share data in a  Interoperability enables 
beneficiarys EHR across multiple systems.10   the secure exchange of 
HIEs can exist within a single care organization  electronic health 
or across multiple care organizations.  They  information with, and use 
may receive and transmit data from a variety  of electronic health 
of different EHRs, and because of  information from, other 
interoperability, ensure that the information is  health IT without special 
useful when received by disparate systems.11   effort on the part of the 
user. 
HIEs vary in both type and reach.  They can be 
State, nonprofit, or government-sponsored 
networks that serve local, regional, or State-wide areas.  In some cases, ONC 
has administered funding to States to expand HIEs.12  EHR vendors and 
national exchange networks may also provide HIE services. 
 
Accountable Care  ACOs are composed of doctors, hospitals, or other healthcare providers that 
come together voluntarily to coordinate high-quality care for their patients 
Organizations 
and agree to be accountable for the total cost and quality of the care 
provided.  ACOs also work to improve what is known as population 
 
10 ONC, Health Information Exchange (HIE).  Accessed at https://www.healthit.gov/providers-
professionals/health-information-exchange/what-hie on November 1, 2018. 
11 See 42 U.S.C.  300jj(9) for the complete statutory definition of interoperability. 
12 ONC, Getting Started with HIE.  Accessed at https://www.healthit.gov/topic/health-it-
basics/getting-started-hie on November 1, 2018. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  3 
OEI-01-16-00180  healthi.e., the health outcomes of a group of individuals, including the 
distribution of such outcomes within the group.13   
ACOs that participate in CMSs alternative payment models can reward 
providers financially for improving quality of care and reducing unnecessary 
costs.  When ACOs meet certain benchmarks for reducing Medicare 
spending while also achieving certain scores on quality measures, they can 
share in the savings.14    
Two of CMSs alternative payment models in which ACOs participate are the 
Medicare Shared Savings Program (MSSP), a permanent national program, 
and the Next Generation ACO Model (Next Generation), a model tested 
under the authority of the Center for Medicare and Medicaid Innovation.  
These models differ in how much risk the ACOs accept and how much of 
any savings the ACOs can share.  Next Generation ACOs typically accept 
greater risk than MSSP ACOs, and some MSSP ACOs can currently accept 
no downside risk.15 
ACOs in the MSSP must have at least 5,000 fee-for-service Medicare 
beneficiaries, and Next Generation ACOs must have at least 
10,000 beneficiaries; both types of ACOs must also agree to participate as 
an ACO for a minimum number of years, which varies according to the 
program and the model and starting year.  ACOs are accountable for the 
total cost of care for the beneficiaries they serve even if those patients 
receive care outside the ACOs.16  To be eligible for financial rewards and 
avoid financial penalties, ACOs must report data to CMS and meet quality 
performance standards and financial benchmarks that CMS sets.17 
ACOs can be networks of hospitals, specialists, and providers of post-acute 
care.  Primary care physicians can coordinate a patients medical care in an 
effort to deliver high-quality care while avoiding unnecessary services such 
as duplicative tests.  For example, a primary care physicians staff could 
coordinate care by organizing a patients services, such as visits to 
specialists, post-acute care treatment, and social services such as Meals on 
Wheels. 
 
Departmental  HHS has proposed or is part of several initiatives that would further the role 
of health IT in care coordination and would affect ACOs.  HHS is also 
Initiatives 
 
13 David Kindig, MD, PhD and Greg Stoddart, PhD, What is Population Health? American 
Journal of Public Health, March 2003; 93(3): 380383. 
14 CMS, Accountable Care Organizations.  Accessed at 
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html on 
September 25, 2018. 
15 CMS, Next Generation ACO Model.  Accessed at 
https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/ on November 1, 2018. 
16 42 CFR  425.100. 
17 42 CFR  425.500. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  4 
OEI-01-16-00180  engaged in the Regulatory Sprint to Coordinated Care, a multi-agency 
initiative to address barriers to care coordination.18 
ONCs Iniatives: In January 2018, ONC published a draft of its Trusted 
Exchange Framework and Common Agreement, designed to help achieve 
nation-wide interoperability and data exchange across disparate health 
information networks.  ONC plans to achieve this by outlining a common 
set of principles as well as minimum terms and conditions for trusted data 
exchange.19  In March 2019, ONC issued a proposed rule implementing 
certain provisions of the 21st Century Cures Act with the purpose of 
advancing interoperability and supporting the access, exchange, and use of 
electronic health information.20 
CMSs Initiatives: CMS has recently introduced regulatory changes and new 
initiatives that could significantly affect both ACOs and health IT.  In 
December 2018, CMS published a final rule that makes changes to MSSP to 
encourage ACOs to transition to performance-based risk more quickly.  The 
rule also expands telehealth payments for certain services regardless of a 
patients geographical location.21  In March 2019, CMS issued a proposed 
rule seeking to improve patients access to their electronic health data and 
enhance interoperability and care coordination across healthcare payers.22 
ONC and CMSs Strategy To Reduce the Administrative Burden of 
Health IT and EHRs: In November 2018, ONC and CMS released a draft 
strategy to reduce the burden that frontline healthcare providers face in 
using health IT tools.  The strategy aims to: 
 
  reduce the effort and time required for healthcare providers to 
record information in EHRs at the point of care; 
  reduce the effort and time required to meet reporting requirements 
for clinicians, hospitals, and healthcare organizations; and 
  improve the functionality and ease of use of EHRs. 
 
 
18 HHS, Secretary Azar Highlights Recognition of HHS as Top Agency for Regulatory 
Reform.  Accessed https:/www.hhs.gov/about/news/2018/10/17/secretary-azar-highlights-
recognition-of-hhs-as-top-agency-for-regulatory-reform.html, on April 19, 2019.  See 83 Fed. 
Reg. 64302 (Dec. 14, 2018), 83 Fed. Reg. 43607 (Aug. 27, 2018), and 83 Fed. Reg. 29524 (Jun. 
25, 2018). 
19 ONC, Draft Trusted Exchange Framework, January 5, 2018.  Accessed at 
https://www.healthit.gov/sites/default/files/draft-trusted-exchange-framework.pdf on 
November 1, 2018. 
20 84 Fed. Reg. 7424 (Mar. 4, 2019). 
21 83 Fed. Reg. 67816 (Dec. 31, 2018). 
22 84 Fed. Reg. 7610 (Mar. 4, 2019). 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  5 
OEI-01-16-00180  The draft strategy also recommends actions for HHS to take to address 
these issues.23 
MyHealthEData initiative: In May 2018, the White House Office of American 
Innovation announced the MyHealthEData initiative, a Government-wide 
collaboration that aims to ensure that patients can access and control their 
healthcare data easily, safely, and securely.  Several HHS agencies are part 
of the initiative, including CMS, ONC, and the National Institutes of Health.24 
Through the MyHealthEData initiative, CMS launched Blue Button 2.0, which 
is a software tool (i.e., an application programming interface, or API) that 
contains data from Medicare Parts A, B, and D for 53 million beneficiaries.  
Blue Button 2.0 is designed to create a standards-based API that allows 
software developers to design applications that enable Medicare 
beneficiaries to connect their claims data to services they trust.25  CMSs 
March 2019 proposed rule seeks to expand the use of the APIs similar to the 
Blue Button 2.0 to Medicare Advantage organizations, State Medicaid 
programs, Medicaid managed care plans, and others.26 
 
Related Work  The Office of Inspector General (OIG) has conducted work on both ACOs 
and health IT.  For ACO-related work, OIG found that over the first 3 years 
of the program, most MSSP ACOs reduced Medicare spending and 
generally improved the quality of the care they provided.27  OIG is currently 
evaluating ACOs specific strategies to reduce spending and improve 
quality.28 
Related OIG work on health IT has examined hospitals use of antifraud 
safeguards in their EHRs, hospitals contingency plans for EHR outages, and 
CMSs EHR incentive payments.  OIG found that nearly all hospitals with EHR 
technology had in place the recommended safeguards against fraud and 
abuse, but that such hospitals may not be using them to their full extent.29  
 
23 ONC and CMS, Strategy on Reducing Regulatory and Administrative Burden Relating to the 
Use of Health IT and EHRsDraft for Public Comment.  Accessed at 
https://www.healthit.gov/topic/usability-and-provider-burden/strategy-reducing-burden-
relating-use-health-it-and-ehrs on December 12, 2018. 
24 CMS, Trump Administration Announces MyHealthEData Initiative at HIMSS18.  Accessed at 
https://www.cms.gov/newsroom/fact-sheets/trump-administration-announces-
myhealthedata-initiative-himss18 on August 21, 2018. 
25 CMS, Blue Button 2.0.  Accessed at https://bluebutton.cms.gov/#value-and-use-cases on 
August 21, 2018. 
26 84 Fed. Reg. 7610 (Mar. 4, 2019). 
27 OIG, Medicare Shared Savings Program Accountable Care Organizations Have Shown 
Potential for Reducing Spending and Improving Quality, OEI-02-15-00450, August 2017. 
28 OIG, Accountable Care Organizations Strategies Aimed at Reducing Spending and 
Improving Quality, OEI-02-15-00541. 
29 OIG, Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR 
Technology, OEI-01-11-00570, December 2013.  OIG has done additional work on ACOs, 
including A-09-17-03010. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  6 
OEI-01-16-00180  CMS and ONC concurred with OIGs recommendation that audit logs, which 
capture data elements such as date, time, and user stamps, be operational 
at all times.  ONC issued proposed rules for the certification of health IT that 
included proposals addressing the operational status of audit logs.30  
However, ONC received mixed reactions to the proposal and decided that 
no further changes to the certification criteria were necessary.31  OIG also 
found that almost all hospitals reported having written EHR contingency 
plans, and that most hospitals also reported having implemented 
recommended practices, such as maintaining backup copies of EHR data 
offsite, supplying paper medical record forms for use when the EHR is 
unavailable, and training and testing staff on contingency plans.32  Finally, 
OIG audited CMSs EHR incentive payments to providers and found that 
CMS paid hundreds of millions of dollars to providers who did not comply 
with Federal requirements.33   
 
Methodology  Scope.  We based this data brief on our analysis of interviews that we 
conducted during site visits to six Medicare ACOs.  We considered the 
following factors when selecting ACOs: 
  high performance on a quality measure focused on care 
coordination and patient safety; 
  a minimum of 3 years of experience as a Medicare ACO; 
  geographic variation; and 
  recommendations from CMS and ONC regarding ACOs with well-
established infrastructures for health IT. 
The site visits took place during April and May 2018.   
Interviews.  Each site visit consisted of interviews with ACO administrative 
and technical staff as well as separate interviews with clinical staff.  We 
asked specifically about the ACOs EHR systems, the extent to which they 
use HIEs, how they leveraged population-level data, their patients use of 
health IT tools, and any other areas in which the ACOs used health IT to 
coordinate care.  Interviews with clinical staff generally covered the efficacy, 
efficiency, and usefulness of health IT in their respective practices.   
Questionnaire.  Prior to the site visits, we sent each ACO a questionnaire 
that sought basic demographic information (e.g., the type of ACO, how long 
the ACO had been a Medicare ACO, its number of providers, its number of 
Medicare beneficiaries, etc.) and whether it uses common health IT tools.   
 
30 79 Fed. Reg. 10904 (Feb. 26, 2014) and 80 Fed. Reg. 16846 (Mar. 30, 2015). 
31 80 Fed. Reg. 16846 (Mar. 30, 2015) and 80 Fed. Reg. 62656 (Dec. 11, 2015). 
32 OIG, Hospitals Largely Reported Addressing Requirements for EHR Contingency Plans,  
OEI-01-14-00570, July 2016. 
33 OIG, Medicare Paid Hundreds of Millions in Electronic Health Record Incentive Payments 
That Did Not Comply With Federal Requirements, A-05-14-00047, June 2017. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  7 
OEI-01-16-00180  Analysis.  We conducted qualitative analysis of our interviews to identify 
commonalities, differences, and challenges in how the ACOs with which we 
spoke use health IT to coordinate care.  We used the content of our 
interviews to analyze how the ACOs use health IT to facilitate care 
coordination at the point of care for each patient as well as for their entire 
patient populations.  In examining health IT at the point of care, we 
considered how ACOs use EHRs and HIEs and the challenges that they face 
in using these tools.  We also assessed whether and how the ACOs 
leveraged population-level analytics to enhance care and the extent to 
which their patient populations engaged with the health IT tools available to 
them.  We based the bulk of our analysis on our discussions with the ACOs 
administrative and technical staff.  Where appropriate, we included 
information from our discussions with providers.    
Limitations.  We based our analysis on information that the ACOs provided 
during OIGs site visits.  We did not independently verify the information 
provided by the ACOs during the interviews beyond confirming basic 
demographic information provided by the questionnaires sent prior to the 
site visits.  We do not endorse any of the strategies that ACOs discussed 
with us.  We also based our analysis on the six ACOs that we visited for this 
study, and the results are not generalizable to a larger population of ACOs. 
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency. 
   
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  8 
OEI-01-16-00180  A Brief Profile of the Medicare Accountable 
Care Organizations We Visited 
We visited six Medicare ACOs with established health IT infrastructure.  Our purposive selection of the six 
was based in part on suggestions by CMS and ONC. 
 
 
ACO 1    ACO 2   
Number of Medicare  7,000    Number of Medicare  30,524 
beneficiaries  beneficiaries 
 
Number of physicians  152  Number of physicians  2,145 
Years as a Medicare ACO  6    Years as a Medicare ACO  7 
ACO type  MSSP  ACO type  Next Generation 
 
Other notes: ACO 1 is physician-led and works  Other notes: ACO 2 is physician-run and includes 
directly with teams of clinicians, care coordinators,     partnerships with regional practices, hospitals, labs, 
and support staff to coordinate care.  and nursing homes. 
 
ACO 3      ACO 4   
Number of Medicare  30,000  Number of Medicare  72,651 
 
beneficiaries  beneficiaries 
Number of physicians  1,400    Number of physicians  5,173 
Years as a Medicare ACO  7  Years as a Medicare ACO  6 
 
ACO type  Next Generation  ACO type  MSSP 
 
Other notes: Sixty percent of ACO 3s physicians are  Other notes: ACO 4 is a physician-led partnership 
independent or part of a physicians group.    composed of 10 smaller physician organizations. 
 
 
 
ACO 5    ACO 6   
 
Number of Medicare  22,000  Number of Medicare  51,918 
beneficiaries  beneficiaries 
 
Number of physicians  750  Number of physicians  2,996 
 
Years as a Medicare ACO  7  Years as a Medicare ACO  7 
ACO type  Next Generation    ACO type  Next Generation 
Other notes: ACO 5 is a network of healthcare  Other notes: ACO 6 is a partnership among 
 
providers including general practices, specialists,  multiple hospitals, primary care practices, specialty 
and hospital partners.    practices, and other healthcare providers. 
 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  9 
OEI-01-16-00180  Coordinating at the Point of Care: Electronic 
Health Records 
 
The promise of EHRs 
 
EHRs hold the potential to integrate and organize a patients health information and facilitate 
 
its instant distribution among all providers involved in the patients care.  EHRs can offer 
 
access to evidence-based tools that providers can use to make decisions about a patients 
 
care, both improving patient outcomes and avoiding harm.  EHRs also hold the potential to 
reduce unnecessary costs b y avoiding duplicative tests or treatments and by lowering the 
administrative costs of information-sharing. 
 
 
 
 
Key Takeaways 
  Some ACOs avoided interoperability challenges by using a single EHR 
system across their provider networks. 
  ACOs that used multiple EHR systems had to rely on other means to 
share data between providers and to coordinate care. 
  Whether using single or multiple EHR systems, ACOs faced challenges 
from physician burnout stemming from the workload of managing EHRs 
and alarm fatigue due to constant EHR alerts. 
 
Discussion  ACOs Using a Single EHR: Using a single EHR system enhanced ACOs 
ability to overcome interoperability challenges and coordinate care.  For 
example, in one ACO that mandates a single EHR across its network, all 
providers have access (through the EHR system) to a provider portal that 
contains a patient care checklist.  As a result, all members of a patients care 
team can stay up to date on the patients current health status and any tasks 
for which they are responsible.  Providers consult this checklist at the point 
of care.  Any new data that they entersuch as vital signs or referralsare 
available in real time to all providers in that ACOs network.  Alerts that the 
portal generates are routed to the appropriate members of a care team, 
and are also kept in a central inbox, similar to an email inbox.  Items are 
removed or checked off once they are addressed.  Users can customize 
the provider portal by practice specialty to best reflect their particular needs.  
Hospitals in the ACO can also access the data through a Web portal.  Notes 
made in the portal can also be forwarded to care teams and other 
caregivers (such as specialists). 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  10 
OEI-01-16-00180  Another ACO we visited also mandates a single EHR for its providers.  Its 
EHR system has built-in templates, 
but it also has tools that allow the  The Physician Perspective on Using 
ACO to use feedback from  a Single EHR System 
providers to develop its own 
Providers have access to up-to-date 
care-management templates.  As 
data regarding patient needs, gaps 
providers enter new data into the 
in care, and areas where they need 
EHR, all providers have instant 
to focus. This reduces duplication. 
access to the data.  Care-
management teams receive daily reports for all admissions to, discharges 
from, and transfers to and from any hospital that provides data to the 
States HIE.   
ACOs Largely Using a Single EHR:  Seamless care coordination is more 
challenging when ACO providers use more than one EHR system.  One ACO 
that we visited employs about half of its providers directly, and these 
providers must use a single EHR system.  Of the remaining providers, about 
a third use compatible systems from the same vendor.  Thus, for the 
majority of the physicians in this ACO, data collected at the point of care are 
shared easily and instantly.  However, the rest of the ACOs providers used 
EHR systems that could not easily share data with other providers in the 
ACOs network.  For these providers, the ACO suggests templates that the 
providers can use to customize their EHRs to be similar to those in the 
single EHR system that the ACO requires for the providers it employs 
directly.  However, these providers do not have to use the template, and in 
some cases their respective EHR systems do not support it.  Furthermore, 
these providers have only read-only accessnot write accessto the 
EHRs that the directly employed providers use, and they do not receive data 
from those EHRs in real time.  These providers must take the additional step 
of checking the EHRs to see information about their patients. 
 
ACOs that Use Many EHRs: The ACOs that use many EHR systems do not 
rely on them to play a central role in coordinating care.  Providers in one 
such ACOs service area cannot easily share data electronically, even when 
using the same EHR vendor, because they have different versions of the 
EHR software.  Instead, these providers generally coordinate care by 
telephone or email at the practice level rather than at the ACO level.  This 
could impose greater burden on providers.  To assist providers, the ACO 
has established a committee for clinical management oversight with 
clinician leads from its various providers.  The committee discusses issues 
that arise across providers and shares best practices regarding care 
coordination.  
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  11 
OEI-01-16-00180  Another ACO that we visited uses a third-party tool to enable providers to 
share information to coordinate care, given the variety of EHR systems in 
use.  This third-party tool includes 
a dashboard, updated daily, with  The Physician Perspective on 
information on patients such as  Working With Multiple EHR Systems 
recent events, lab results, 
A physician who worked with two 
diagnoses, medications, and gaps 
different EHR systems in his practice 
in care.  The tooleffectively 
saw firsthand the need for data 
acting as an HIEallows the ACO 
standardization, particularly when 
to gather data from 80 percent of 
trying to integrate nonelectronic 
participating providers across 
data from outside providers.  
44 different EHR systems.  Four 
local hospitals also use the tool, which gives the ACO discharge data on 75 
to 80 percent of its patient population.  The providers get information on 
each patients status and can then begin to work on the patients 
post-discharge care.  The ACO covers the cost of the tool for providers in its 
network.  
Challenges  EHR Burnout: Staff from some of the ACOs cited provider weariness from 
EHRs as a challenge, regardless of whether the ACOs used a single or 
multiple EHR systems.  This includes everything from the additional 
workload from managing EHRs to alarm fatigue resulting from constant 
EHR alerts for things such as 
potential drug interactions and  The Physician Perspective on EHR 
notifications when patients are  Burnout 
admitted to or discharged from 
According to one physician, 
hospitals.  Providers report that the 
providers are leaving primary care 
extra time required to work with 
for other areas to avoid information 
EHRs detracts from time spent with 
overload. 
patients.  Some ACOs are trying to 
address this by reducing the amount of data that providers see without 
adversely affecting providers ability to coordinate care.  One of these ACOs 
is shifting its model away from alerts in favor of a more on-demand 
approach at the point of care, so that providers see data pertinent to their 
specific needs.   
Another ACO uses a care coordination team to triage the data that 
providers see.  The team analyzes the data to understand the various 
services that patients need or have already received, and it then conducts 
outreach to patients.  Providers do not get all information about their 
patients; some data goes directly to a care coordinator, who drives the 
outreach.  The ACO sends providers aggregate data on patients who have 
already received services, which allows the providers to identify those 
patients who have not received services.  This results in a much smaller list 
of patients for whom providers must actively coordinate care.  
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  12 
OEI-01-16-00180  Coordinating at the Point of Care: Health 
Information Exchanges 
 The promise of HIEs 
HIEs can enable care coordination by allowing interoperability across EHRs and other health IT 
systems, and they can create a repository from which disparate providers can obtain 
 
standardized data.  The use of HIEs has the potential to bolster care coordination by avoiding 
readmissions, avoiding medication errors, improving diagnoses, and decreasing duplicative 
testing.   
 
 
Key Takeaways 
  Some ACOs had access to robust HIEs that supply a great deal of useful 
patient data. 
  However, most of the ACOs we visited had access to HIEs with little or 
incomplete data, making it difficult to coordinate care when patients 
saw providers outside the ACOs networks. 
 
Discussion  Robust HIEs: Two of the ACOs we visited use HIEs that provide useful 
patient data.  One of these ACOs has an independently run, 
member-supported HIE developed and maintained by a private entity and 
partially funded by its State.  Through the HIE, ACO staff have a single data 
sourceavailable to them in real timefor nearly all patients.  This allows 
care management teams to support patients according to patients risk 
levels and their needs for condition management.  These teams receive 
daily reports for all admissions to, discharges from, and transfers to and 
from any hospital providing data to the HIE.  Not all hospitals in the State 
participate in the HIE (e.g., hospitals near the State border and in more rural 
settings are less likely to participate); however, most do.   
One ACO uses two HIEs, each of which covers part of the ACOs service 
area.  The ACO helped to develop one of these HIEs.  Both HIEs offer alerts 
on admissions, discharges, and transfers as well as tracking of prescription 
drugs.  According to the ACO, provider adoption of the HIEs is high as a 
result of assistance from ONC and a State incentive program; however, not 
all of the providers with which the ACO works use the HIEs.  The ACO is 
considering using a third-party vendor to obtain data from providers that 
do not participate in the HIEs.   
HIEs With Little or Incomplete Data: In some cases, ACOs had access 
to HIEs but could not get useful data from them.  One such ACO has access 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  13 
OEI-01-16-00180  to a State-wide HIE but does not find it as useful because of the lack of 
provider adoption.  The HIE has not yet reached a critical mass where it 
has enough participants to make it useful.  According to the ACO, 
participation in the HIE is currently limited to big players because smaller 
entities cannot afford to participate or choose not to participate.   
Another ACO that has access to a State-wide HIE does not use it, because 
the ACO has concerns about the accuracy of the HIEs data (other than data 
on admissions and discharges, which the ACO said were accurate).  This 
ACO is examining potential ways it can use the HIE.  
In one State, two ACOs reported 
The Physician Perspective on HIEs 
relying on alternative solutions for 
With Little or Incomplete Data 
health IT because providers have 
not yet widely adopted the States  Its like having an ATM card thats 
HIE.  One of these ACOs uses a  only accepted at one bank. 
health IT system that offers some 
interoperability within the State.  The ACOs providers have access to a daily 
feed of patient utilization of services at different points of care.  As a result, 
providers are able to maintain some level of care coordination for their 
patients, at least for patients who see providers within the ACOs network.  
The other ACO uses a different third-party health IT tool to facilitate 
interoperability across its provider network.  This tool enables the ACO to 
obtain standardized data for 75 to 80 percent of its patient population. 
 
Challenges  Getting Data From Providers Outside the ACO: Some ACOs we visited 
faced challenges when sharing data with providers who are outside the 
ACO network and do not participate in an HIE.  For example, one ACO told 
us about a situation in which an oncology patient had been hospitalized 
and the hospital physician was unable to retrieve records from the patients 
oncologist.  Some ACOs receive data from outside providers via 
nonsearchable PDF files or other 
types of files that are not easily  The Physician Perspective on 
searchable, which means that  Getting Data From Outside 
providers need extra time to find  Providers 
the information they need at the 
Searching for data from an outside 
point of care.   
EHR system can take so long that it 
To overcome such challenges, one  is often faster to redo a test. 
of the ACOs uses a Web portal as 
a stopgap method to obtain data from providers outside the ACO network.  
The Web portal includes a feed of admissions, discharges, and transfers that 
automatically alerts physicians at the ACO of patient admissions and 
emergency department visits.  Nurses and case managers use discharge 
information to coordinate post-discharge care.     
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  14 
OEI-01-16-00180  Coordinating at the Population Level:  
Analytics 
 
The promise of population-level analytics 
Aggregated electronic health data can enable health care providers to measure population 
 health to better understand prevention, diagnosis, and treatment.  Providers and healthcare 
organizations can use information generated by population health tools to track and improve 
clinical outcomes and lower healthcare costs. 
 
 
Key Takeaways 
  Most of the ACOs we visited use population-level analytics to inform 
their care coordination by identifying and grouping patients according 
to the potential severity and cost of their health conditions.  
  Fewer ACOs use analytics to customize care to an individual patients 
needs.   
  ACOs see value in including data on social determinants of health, but 
they face challenges in collecting these data. 
 
Discussion  Prediction and Risk Stratification With Population-Level Data: Most of the 
ACOs we visited use population-level analytics to identify and group patient 
populations according to the potential severity and cost of their health 
conditions, a practice known as risk stratification.  By identifying such 
patients, ACOs can use specialized 
The Physician Perspective on 
outreach and coordination 
Population-Level Analytics 
strategies to help the patients 
better manage their conditions  Analytics have improved the ACOs 
and improve their health  ability to identify gaps, reduce 
outcomes.      duplication, and create safety nets.   
For example, one ACO analyzes 
data such as claims from CMS and admissions to identify patients who have 
more complex needs and require a greater level of care coordination.  This 
ACO uses analytics to begin coordinating care for patients before their 
initial visit to the ACOs providers.  The ACO prospectively analyzes claims 
and other available patient data as soon as CMS sends the list of the ACOs 
patients.  The ACO assesses each patients risk level and preemptively sets 
up care management strategies.  For example, the ACO identifies patients 
with chronic conditionssuch as end-stage renal diseaseand focuses its 
care coordination on these patients.  Patients can consent to increased care 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  15 
OEI-01-16-00180  coordination to help them better manage these types of complex 
conditions.  If the patients consent, the ACO shares their data with all 
relevant providers who are then able to see special flags (e.g., high risk, 
gaps in care) at the point of care.     
Some ACOs we visited had a well-developed method to stratify risk, while 
others methods were still in more nascent stages.  One ACO said that its 
current method is manual and creative.  This ACO is considering both 
services available from outside companies and in-house development to 
improve its methods to stratify risk.  Another ACO described its use of 
predictive analytics as being in its infancy, but stated that it is devoting 
significant resources to expanding its capabilities.  
Another ACO that we visited uses data from claims and EHRs to create 
predictive models focusing on specific aspects of population management, 
such as hospitalization, emergency room use, and total costs of care.  It 
analyzes the data and assigns risk scores to patients.  These risk scores 
appear in the patients EHRs, making them available for providers to review 
and act on at the point of care. 
A third ACO described a targeted outreach program in communities in 
which it identified high rates of tobacco use.  ACO staff work with staff from 
home health agencies to develop strategies to manage chronic obstructive 
pulmonary disease in these communities.  
Using Population Data To Customize Patient Care: Fewer ACOs use 
analytics to customize care to the needs of individual patients.  One of these 
ACOs developed a registry for high-risk patients who frequently visit 
emergency rooms, and it designed care plans for those patients.  These care 
plans rely on coordination across multiple providers.  When a patient on the 
registry arrives at the emergency room, an ER Navigator nurse is notified 
and performs an assessment to see whether the patient can be diverted to 
an alternative care setting.  This alert is sent electronically and is integrated 
with the patients EHR.  The alert also goes to other members of the care 
team, such as the primary care physician and (in the case of patients with 
end-stage renal disease) a nephrologist.  On the patients discharge, the 
care team coordinates a plan for the patient, follows up with the patient to 
make sure she adheres to the care plan, and works to address any barriers 
to adherence.  This ACO has a similar registry for patients who are at high 
risk of being readmitted to the hospital.  The ACO also uses population-
level data to determine where it should focus its clinical interventions and 
whether these interventions are effective.  Additionally, these data help 
identify potential gaps in care as well as connections to community 
resources to improve care management.   
   
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  16 
OEI-01-16-00180  Challenges  Volume of data: ACOs face a challenge in finding the best uses for all the 
available data.  One ACO explained that as data are becoming increasingly 
available, questions emerge at both the population level and point of care 
about how to best use them.  Several providers stated that it is challenging 
to determine how to use all of the data to actually benefit patients. 
Conversely, lack of data can also present challenges to effectively using 
population-level analytics to 
The Physician Perspective on Having 
coordinate care.  Claims and other 
Too Much Data 
data from outside an EHR may be 
untimely, incomplete, or of poor  How is this information valuable?  
quality.  As a result, an ACO may  How does this actually help the 
have difficulty developing  patient? 
a comprehensive understanding of 
the patient populations needs and risks.   
Data on social determinants of health: Several of the ACOs are in the early 
stages of incorporating data on where patients live, patients access to food 
and transportation, and other factors that shape the conditions of daily 
lifeinto their population health analytics.  These factors are commonly 
called social determinants of health.34  Other ACOs plan to collect these 
data in the future.  However, ACOs cited challenges with collecting social 
determinants data, including where and how to collect them.   
Half of the ACOs that we visited currently incorporate data on social 
determinants into their analytics to some extent.  One of these ACOs has 
a large population that is dually eligible for Medicare and Medicaid, and its 
patients may face greater difficulty in accessing basic resources.  This ACO 
incorporates data directly from EHRs on patient housing, nutrition, and 
access to transportation.  ACO providers and staff obtain the data from 
patients during new patient visits, and by going onsite to various 
community organizations where they manually abstract records.  Another 
ACO encourages patients to provide such data through a survey that 
providers administer electronically at the beginning of visits.  Because the 
ACOs EHR system has no standard format for recognizing data on social 
determinants, the ACO is developing a way to automatically identify and 
capture these data from patient narratives in EHRs.  
One of the ACOs that is currently unable to integrate social-determinants 
data and other external population-level data into its EHRs is working with 
an outside company to develop this capability.   
   
 
34 HealthyPeople2020, Social Determinants of Health.  Accessed at 
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health 
on August 20, 2018. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  17 
OEI-01-16-00180  Coordinating at the Patient Level: Patients 
Use of Health IT  
 
The Promise of Patient-Facing Health IT Tools 
 
Giving patients access to health IT tools can allow them to become active participants in their 
care.  Patients can use thes e tools to monitor their conditions and to better track their 
medications and follow their care plans.  Patients can also use these tools to communicate 
 
remotely with providers, often allowing patients to talk with specialists in areas underserved by 
 
such providers.  
   
Key Takeaways 
  ACOs offer patients few health IT tools other than online portals to 
EHRs. 
  ACOs cite payment limitations as a challenge to implementing 
telehealth. 
 
Discussion  Patient Portals: At a minimum, each ACO offered patients access to 
an online portal that allowed patients to access their EHRs in the ACOs EHR 
systems; CMSs Meaningful Use incentive payments require EHRs to include 
this feature.35  Patients can access lab results, view upcoming appointments, 
and send messages to their providers.  The ACOs told us that patient use of 
these portals varied.  At one ACO, younger patients had the highest 
utilization of the portal, whereas at another ACO, staff said that their patient 
population overall was highly engaged with the portals (though staff 
acknowledged that some of this use by older patients is likely through proxy 
users like patients children).  Among the ACOs that each used multiple EHR 
systems, the features of the patient portals differed across the EHR systems 
and their corresponding groups of providers. 
Telehealth: Several ACOs use some kind of telehealth system by which 
patients can speak with providers from a remote location.  One of these 
ACOs uses telehealth routinely, while the others are piloting various 
services.  The ACO that regularly uses telehealth offers both asynchronous 
services (in which the patient and provider do not talk in real time) and 
synchronous services (in which they do speak in real time).  For the 
asynchronous services, patients can consult with specialists; the patient 
sends a message to which the specialist replies at a later time.  For the 
synchronous services, patients in areas with fewer behavioral health 
 
35 42 CFR  170.314(e)(1). 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  18 
OEI-01-16-00180  specialists can have real-time, remote appointments with those specialists.  
Care managers work with patients to set up the appointments.  Patients 
must travel to their primary care providers office, and can speak remotely 
with the specialist from there.  Two other ACOs are piloting telehealth 
services for behavioral health.  One of these ACOs offers the services via 
telephone, but patients in crisis can have a virtual visit with a specialist at 
their primary care providers office.  The other ACO offers telehealth services 
via computer, smartphone, and tablet. 
Interactive Voice Response Systems: Two ACOs use interactive voice 
response systems (i.e., automated phone calls).  These systems call patients 
to remind them of wellness and preventive care visits, andfor high-risk 
patientsto give them educational information.  The systems also assess 
patients conditions.  For example, patients who experienced heart failure 
will get a daily call at home.  If a patients responses to questions contain 
certain keywords, the system notifies a nurse who then calls the patient.  
ACOs have the ability to assign specific voice-response modules to patients 
according to their respective situations (e.g., post-discharge from 
a hospital).  The system also helps avoid duplication of services and 
educates patients caregivers, especially in transitions between care settings. 
Other Patient-Facing Health IT Tools: One ACO is piloting several different 
health IT tools, though these pilots are mostly for a small number of 
patients: 
  Software applications for management of health conditions (e.g., 
diabetes).  The goal is to expand to populations that may not need 
complex care management, but do need coaching. 
  A medication-tracking application that notifies designated people 
when patients miss taking medications.  The application runs on 
smartphones or ACO-provided tablets. 
  An automated medication dispenser that alerts patients when it is 
time to take the medication.  It is monitored remotely by 
a pharmacy. 
 
Challenges  Telehealth Availability: ACOs cited the limitations on payment for telehealth 
services as a challenge to implementing such services.  In a 2018 report to 
Congress, CMS acknowledged potential barriers in current fee-for-service 
coverage that might prevent the expansion of telehealth services among 
Medicare beneficiaries.  Such barriers include restrictions on the types of 
originating sites that are eligible for payment under Medicare fee-for-
service (e.g., requiring the site to be located in certain types of rural areas 
and not allowing a patients home to be an originating site).36  Another ACO 
considered a telehealth pilot, but logistical issues regarding behavioral 
health were one of the reasons it did not go forward with it.  For example, 
 
36 CMS, Information on Medicare Telehealth, November 15, 2018. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  19 
OEI-01-16-00180  some providers were apprehensive about how the ACO could establish 
protocols for managing treatment and liability for patients with depression. 
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  20 
OEI-01-16-00180  CONCLUSION 
The six Medicare ACOs we visited have used health IT to better coordinate 
care for their patients in a variety of ways.  However, the full potential of 
health IT has not yet been realized.  ACOs differ as to the extent to which 
they can rely on health IT tools, in some cases because those tools are not 
sufficiently robust.  Achieving the interoperability needed for seamless care 
coordination places burdens on ACOs to either invest in a single EHR 
system, or use additional methods, such as non-health IT means like faxes 
and phone calls, to communicate health information.   
In the ACOs we visited, it appears that those ACOs that use single EHR 
systems were able to maximize that tool for care coordination.  This may be 
in part because those ACOs have full access to patient information for all 
the providers in their networks.  These ACOs still had to rely on other health 
IT tools to obtain data from providers outside their networks. 
The impact of other health IT toolssuch as HIEs, population analytics, and 
patient-facing toolson coordinating care for patients is less apparent 
across ACOs.  This may stem partly from the range of challenges that ACOs 
face in using these tools for care coordination.  One such challenge is the 
cost of expanding the functionality of these tools.  Another challenge is the 
limited nature of some HIEs data, which hampers ACOs ability to manage 
data across patients, providers, and health systems.  These challenges are 
not unique to ACOs; in fact, many types of healthcare organizations 
experience them as well.  Many see a network of high functioning and 
comprehensive HIEs as a linchpin of interoperability, but the promise of 
such a network has not yet been realized. 
Some of HHSs proposed initiatives might address concerns and challenges 
that we heard from ACOs.  For example, ONCs Trusted Exchange 
Framework and Common Agreement has the promise of facilitating 
interoperability across health IT networks, which might mitigate the problem 
that ACOs had in accessing data from HIEs with little or incomplete data.  
With interoperability, an ACO would be able to access patient data even 
when patients visit providers outside the ACO.   
ONCs and CMSs draft Strategy on Reducing Regulatory and Administrative 
Burden Relating to the Use of Health IT and EHRs could address the concerns 
regarding physician burnout that ACOs told us about.  The strategy calls for 
the following actions: reducing the regulatory burden of documentation 
requirements for patient visits, partnering with clinical stakeholders 
to encourage adoption of best practices related to documentation 
requirements, and leveraging health IT to standardize data and processes 
related to ordering services.  
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  21 
OEI-01-16-00180  Finally, CMSs December 2018 final rule changing the MSSP ACO model also 
expands telehealth payments for certain services regardless of a patients 
geographical location.  This expansion may address the concerns we heard 
from ACOs about the financial barriers to offering telehealth services.   
HHS has invested heavily in promoting the use of health IT tools because of 
the promise they hold to help patients achieve better outcomes at lower 
costs.  This work showcases some of the advances that ACOs have made as 
well as remaining challenges to fulfilling that promise. 
   
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  22 
OEI-01-16-00180   
ACKNOWLEDGMENTS 
Ivan Troy served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections who conducted the study include Matt Blackburn 
and Joe Chiarenzelli.  Office of Evaluation and Inspections staff who 
provided support include Clarence Arnold and Christine Moritz. 
This report was prepared under the direction of Joyce Greenleaf, Regional 
Inspector General for Evaluation and Inspections in the Boston regional 
office, and Danielle Fletcher, Deputy Regional Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations  23 
OEI-01-16-00180  ABOUT THE OFFICE OF INSPECTOR GENERAL 
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Law 95-452, as amended, is to protect the integrity of the Department of 
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Services 
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