by Jaan Sidorov

First posted on the Disease Management Care Blog on 12/27/2012

Jaan Sidorov, host of Disease Management Care Blog

Pity the hospital CEOs, EVPs and Chairs and their “Accountable Care Organizations” (ACOs). They’ve lined up the doctors, invested in an electronic record, hired some care management nurses and signed the risk contracts.

And then Matthew Press and colleagues come along with thisAJMC article on Care Coordination in Accountable Care Organizations: Moving Beyond Structure and Incentives.

Their message? You may have what’s necessary, but it’s not sufficient. Organization and incentives are not enough.

What’s also needed are:

1. Training: physicians need education on coordination, collaboration communication and teamwork.  The education should be an organizational priority and typically involve course work, observation and feedback with continuous evaluation.  This cannot be accomplished in a one day workshop.  An example of what it might take can be found here.

2. Support tools: since efficient information transfer must to be built into ACOs’ workflows, informal “situation” or “personality” dependent communication between docs and nurses need to be transformed.  An example of the kind of framework that Kaiser instituted can be found here.  While you’re at it, think about HIPAA-compliant texting, wiki-enabled EHR records and patient activity streams.

3. Culture: if front line staff are going to support the delivery of high quality and optimum cost care, the organization will need to protect time for care coordination activities, multi-disciplinary meetings, forums to share best practices and incentives that recognize collaborative behaviors.

Looks like the work has only just begun.

Jaan Sidorov, MD
Jaan Sidorov MD is the Host of the Disease Management Care Blog where he shares his knowledge and insights about medical home, disease management, population-based health care and managed care. He is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He is primary care by training, managed care by experience and population-based care strategies by disposition. The contents of his blog reflect only his opinions and should not be interpreted to have anything to do with any current or past employers, clients, customers, friends, acquaintances or enemies, personal, professional, foreign or domestic.


  1. Jaan, great points! We’re also finding that bridges need to made across ACO participants in a way that transcends EMRs/EHRs, which can vary from group to group and create silos of information… a care coordination migrane! Capturing data in one workflow (e.g. hospital post-discharge) and teeing up appropriate downstream alerts in another provider’s workflow (e.g. primary care practice follow up for newly prescribed Coumadin) becomes critical in achieving the ACO’s performance goals. Easy to do for a Kaiser IDN. Not so much for organizations bolted together as an ACO.

    We’re seeing success by adding cloud app that layers over existing workflow systems and distributes information across all care delivery entities, then triggers decision support to meet ACO objectives. Also, to your points, simplifies Training and Culture transformation.

    Thanks again for pointing out some of the more “practical” considerations as folks start implementing.

  2. I completely agree with Robert, you have mentioned great and valuable points. The way you have explained training, support tools and culture are really understandable.


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