The success of Accountable Care Organizations (ACOs) depends in part on how well providers are able to share pertinent information about their patients.
Today the most common type of electronic exchange is via a Continuity of Care Document (CCD) sent from a hospital or ambulatory provider to another ambulatory provider at discharge or when a referral is made. ACOs present unique challenges for achieving care coordination using electronic information exchange particularly for providers and services operating outside of their traditional network. In an ACO, different organizations practicing along the continuum of care capture different types of information, in different systems at different times and need to exchange the information in less predictable ways. In this article, we share lessons learned from the current state of electronic exchange and interoperability and recommend strategies for overcoming barriers and facilitating care coordination in more complex ACO scenarios.
• New Users and Steeper Learning Curves: Caregivers from long term support, behavioral health and other services representing the social determinants of health may be new to electronic exchange and will have steep learning curves to overcome. Unlike their ambulatory care and hospital counterparts, many of them were excluded from incentive and assistance programs to adopt and use Electronic Health Records (EHRs). The ACO may want to consider providing technical and operational assistance to affiliated organizations that may not have the internal expertise or resources to manage the change.
• Content Validation – ACOs may need to exchange more types of information than is currently captured in most CCDs using the minimum meaningful use data set. While CCD-A are flexible with respect to content, many organizations and EHRs are not prepared to modify them with customized content tailored to the receiver’s need. Content requirements should be evaluated and validated prior to making any technical and workflow changes.
• Format Compatibility – Different types of information exchanged for ACO care coordination may require the use of different document types. For example, a behavioral health assessment may be captured and sent as a PDF. Many vendors are unable to accept a PDF and some can’t reliably exchange a CCD with some other vendors. In our experience working with state-wide HIEs, we have tested exchange between a wide range of EHRs and HISPs and discovered multiple gaps and barriers to true interoperability between them. Checking with an experienced source, like a state-wide HIE can potentially save hundreds of hours troubleshooting and testing a process that has already proven itself to be not ready for prime time.
• Logistics – ACOs will need to share patient information among multiple providers at different organizations using different systems. Well planned use of admissions, discharge and transfer (ADT) notifications will facilitate exchange, but lack of a national provider directory and the need to verify a recipient’s readiness to receive will continue to stymie exchange. CCDs were not designed to be collaborative or “living” documents updated and shared by multiple providers simultaneously. ACOs will need to decide which systems and what information to use for a given purpose as well as ownership and modification rights to ensure accuracy, reliability and transparent versioning. Users may need to be trained on systems other than their own. Teams comprised of providers, coordinators, case managers, IT staff and administrators will be invaluable for prioritizing interoperability use cases, defining requirements and managing the change across disparate organizations. The challenge may be toughest for the least prepared; agencies that manage the social determinants of care and who may be participating in multiple ACOs or shared risk plans.
Conclusion
To be successful, ACOs and other risk sharing models will need highly interoperable systems and a deep understanding of their information sharing needs. Successful teams will be led by clinicians and guided by quality process improvement experts with a deep understanding of the electronic exchange landscape including Direct, HIE, Health Information Service Providers (HISPs), Commonwell, Careverywhere, FHIR, Blockchain and everything in between. Understanding known barriers and viable solutions is invaluable for choosing the right strategy to achieve specific care coordination objectives. A successful one system/one workflow fits all scenario is unlikely and technology may not always be the solution. Resources should be budgeted for assessment, prioritization, workflow design, training, monitoring and sustainment of any new technical or operational exchange process.
Len Levine is a Senior Consultant with Massachusetts eHealth Collaborative and an Account Manager for the Massachusetts Health Information Exchange (Mass HIway).