The new healthcare reform law has resulted in the emergence of accountable care organizations, a new model that focuses on enhancing clinical outcomes and reducing monetary waste in the healthcare system. The ACO model is built on the premise of providing quality care with nontraditional payment models, such as gainsharing or bundled payments.
Occurring alongside the advent of ACOs is the increased move toward adoption of electronic medical records. Starting in 2011, eligible healthcare providers can receive incentive payments if they are able to demonstrate meaningful use of electronic health records and meet criteria set by the U.S. Department of Health & Human Services. Here, Jordan Battani, principal at CSC Health Services, shares six success factors for ACOs and describes the healthcare IT that is necessary to meet those goals.
1. ACO member engagement. ACOs must work toward engaging patient members in such a way that encourages them to participate in their care and in the prevention of their care. Ms. Battani says what's hard for hospitals and other healthcare providers within any ACO model is adopting a more long-term view of the health status of those assigned to the ACO. "When you move into the ACO world, the big conceptual transition is being aware of your members long before they get to the point where they have to use health services and helping them manage their health with the idea they never have to access health services," she says.
A patient portal that provides highly secure personalized access to an underlying EHR is the primary HIT vehicle to support member engagement providing clinical support, access to tailored health information and to customized self maintenance modules for chronic conditions, Ms. Battani says. Hospitals in ACOs should also tap into social media — such as Facebook and Twitter — as a resource that could promote ACO members to become more involved in their health statuses.
2. Cross-continuum care management. ACOs will be responsible for the global care of patients across the entire care spectrum. Many would agree that healthcare is currently fragmented, with patients having multiple physicians with varying versions of prescription lists and so on. Because ACOs will be accountable for the health status of individual members and the costs tied to the delivery of care, ACOs will need to have tightly knit coordination as patients are handed off between different physicians and healthcare organizations.
"The HIT starting point for supporting cross continuum medical management is the patient EHR that can be shared between and among referring and receiving providers," Ms. Battani says. "An enterprise EHR, that all providers have access to, will initially be out of reach for many ACOs, but other options such as health information exchange networks that transfer patient record summaries can be implemented until more comprehensive solutions are possible."
3. Clinical information exchange. Ms. Battani adds the best practice to ensure ACOs successfully deliver care across a continuum is to ensure coordination of care practices and access to patient records across all care venues. Clinical information exchanges add another layer of depth to the idea of cross-continuum care management. Delivering care across a continuum and looking at each ACO member's health status on a global level requires healthcare organizations, physicians and other care providers involved in ACOs to be well informed of each member's health status.
Health information exchanges and enterprise EHRs are two ways ACOs can better exchange clinical information. Mature, well-integrated provider networks will be in a position to quickly develop an EHR approach to support their ACO, while those with less mature organizational integration are likely to begin by leveraging HIE technology for exchanging electronic patient clinical information among system and users. Whatever health IT solution ACOs choose to adopt will largely depend on organizational make-up, maturity and cohesion, Ms. Battani says.
4. Quality reporting. Payment models for ACOs are built around outcomes that are achieved. Some examples of quality indicators that could be measured are readmission rates, the frequency of ED admissions and so on. In order to qualify for the Medicare Shared Savings Program and other ACO initiative programs, it is important that ACOs have information readily available to demonstrate that quality-of-care performance measures are being met.
"Real-time reporting solutions that provide the clinician with actionable information will be an essential tool in managing high-cost inpatient services and preventing avoidable readmissions," Ms. Battani says. "A special challenge ACOs face is coordinating and managing quality reporting across ACO sites and venues. This is where an HIE once again becomes an important ACO resource for enabling the transmittal and receipt of that data for either direct reporting support or creation and maintenance of data warehouses and clinical data repositories."
5. Business intelligence, predictive modeling and analytics. The concept of business intelligence, predictive modeling and analytics can be used as a means to harness the information they have on ACO members' health statuses and histories and use that data to predict what is likely to happen in the future. This is a tremendous paradigm change for healthcare providers who are used to providing care as patients get sick. This change in practices will force healthcare providers in ACOs to be more proactive about members' health and tap into technology as a way to prevent patients from needing medical services in the future.
"Successful business intelligence implementations must include health IT tools to transform and integrate information from multiple sources and systems, apply a variety of analytics and predictive models, and produce outputs that can be used in many different clinical, financial and operational settings," she says. "You can use these tools to create actionable insights for managing patient care, ensuring high quality health outcomes and financial performance. For example, an ACO might be able to identify people who have diabetes and even stratify them further by how severe their diabetes is. Based on that, the ACO could design programs and services for them. It's a way of being more proactive."
Ms. Battani adds that ACOs adopting business intelligence, predictive modeling and analytics should also analyze programs retrospectively to see what services and programs worked. "If you can constantly improve these preventive programs and abandon the programs that aren't helpful, it all ties back to outcomes and quality report," she says.
6. ACO risk and revenue cycle management. Coinciding with the need to expand care to more patients, ACOs will also change the way healthcare providers have traditionally approached revenue cycle management. ACOs are responsible for the quality of services provided as well as all costs tied to rendered services. In the same vein as clinical information exchange, information on bills, payments and services rendered must somehow be shared across all care venues. So ACOs must come up with a way to expand revenue cycle and risk management and tie those financial findings back to the quality of care that was provided.
"To achieve this reorientation and expansion, ACOs will require health IT and applications that enable the ability to recognize and capture data before, during and after the period when individuals become patients,” Ms. Battani says. “You'll want to know about the financial activity happening with patients even when they're not in your facility because it's about expanding services across a continuum of care, even from a financial perspective."
She adds that provider network management and contract management will determine ACO investment in applications and processes that will allow them to pay claims and to manage and distribute ACO revenues to all the participants in care delivery and patient service.
Read CSC Health Service's whitepaper "Health Information Requirements for Accountable Care."
Learn more about CSC Health Services.
Occurring alongside the advent of ACOs is the increased move toward adoption of electronic medical records. Starting in 2011, eligible healthcare providers can receive incentive payments if they are able to demonstrate meaningful use of electronic health records and meet criteria set by the U.S. Department of Health & Human Services. Here, Jordan Battani, principal at CSC Health Services, shares six success factors for ACOs and describes the healthcare IT that is necessary to meet those goals.
1. ACO member engagement. ACOs must work toward engaging patient members in such a way that encourages them to participate in their care and in the prevention of their care. Ms. Battani says what's hard for hospitals and other healthcare providers within any ACO model is adopting a more long-term view of the health status of those assigned to the ACO. "When you move into the ACO world, the big conceptual transition is being aware of your members long before they get to the point where they have to use health services and helping them manage their health with the idea they never have to access health services," she says.
A patient portal that provides highly secure personalized access to an underlying EHR is the primary HIT vehicle to support member engagement providing clinical support, access to tailored health information and to customized self maintenance modules for chronic conditions, Ms. Battani says. Hospitals in ACOs should also tap into social media — such as Facebook and Twitter — as a resource that could promote ACO members to become more involved in their health statuses.
2. Cross-continuum care management. ACOs will be responsible for the global care of patients across the entire care spectrum. Many would agree that healthcare is currently fragmented, with patients having multiple physicians with varying versions of prescription lists and so on. Because ACOs will be accountable for the health status of individual members and the costs tied to the delivery of care, ACOs will need to have tightly knit coordination as patients are handed off between different physicians and healthcare organizations.
"The HIT starting point for supporting cross continuum medical management is the patient EHR that can be shared between and among referring and receiving providers," Ms. Battani says. "An enterprise EHR, that all providers have access to, will initially be out of reach for many ACOs, but other options such as health information exchange networks that transfer patient record summaries can be implemented until more comprehensive solutions are possible."
3. Clinical information exchange. Ms. Battani adds the best practice to ensure ACOs successfully deliver care across a continuum is to ensure coordination of care practices and access to patient records across all care venues. Clinical information exchanges add another layer of depth to the idea of cross-continuum care management. Delivering care across a continuum and looking at each ACO member's health status on a global level requires healthcare organizations, physicians and other care providers involved in ACOs to be well informed of each member's health status.
Health information exchanges and enterprise EHRs are two ways ACOs can better exchange clinical information. Mature, well-integrated provider networks will be in a position to quickly develop an EHR approach to support their ACO, while those with less mature organizational integration are likely to begin by leveraging HIE technology for exchanging electronic patient clinical information among system and users. Whatever health IT solution ACOs choose to adopt will largely depend on organizational make-up, maturity and cohesion, Ms. Battani says.
4. Quality reporting. Payment models for ACOs are built around outcomes that are achieved. Some examples of quality indicators that could be measured are readmission rates, the frequency of ED admissions and so on. In order to qualify for the Medicare Shared Savings Program and other ACO initiative programs, it is important that ACOs have information readily available to demonstrate that quality-of-care performance measures are being met.
"Real-time reporting solutions that provide the clinician with actionable information will be an essential tool in managing high-cost inpatient services and preventing avoidable readmissions," Ms. Battani says. "A special challenge ACOs face is coordinating and managing quality reporting across ACO sites and venues. This is where an HIE once again becomes an important ACO resource for enabling the transmittal and receipt of that data for either direct reporting support or creation and maintenance of data warehouses and clinical data repositories."
5. Business intelligence, predictive modeling and analytics. The concept of business intelligence, predictive modeling and analytics can be used as a means to harness the information they have on ACO members' health statuses and histories and use that data to predict what is likely to happen in the future. This is a tremendous paradigm change for healthcare providers who are used to providing care as patients get sick. This change in practices will force healthcare providers in ACOs to be more proactive about members' health and tap into technology as a way to prevent patients from needing medical services in the future.
"Successful business intelligence implementations must include health IT tools to transform and integrate information from multiple sources and systems, apply a variety of analytics and predictive models, and produce outputs that can be used in many different clinical, financial and operational settings," she says. "You can use these tools to create actionable insights for managing patient care, ensuring high quality health outcomes and financial performance. For example, an ACO might be able to identify people who have diabetes and even stratify them further by how severe their diabetes is. Based on that, the ACO could design programs and services for them. It's a way of being more proactive."
Ms. Battani adds that ACOs adopting business intelligence, predictive modeling and analytics should also analyze programs retrospectively to see what services and programs worked. "If you can constantly improve these preventive programs and abandon the programs that aren't helpful, it all ties back to outcomes and quality report," she says.
6. ACO risk and revenue cycle management. Coinciding with the need to expand care to more patients, ACOs will also change the way healthcare providers have traditionally approached revenue cycle management. ACOs are responsible for the quality of services provided as well as all costs tied to rendered services. In the same vein as clinical information exchange, information on bills, payments and services rendered must somehow be shared across all care venues. So ACOs must come up with a way to expand revenue cycle and risk management and tie those financial findings back to the quality of care that was provided.
"To achieve this reorientation and expansion, ACOs will require health IT and applications that enable the ability to recognize and capture data before, during and after the period when individuals become patients,” Ms. Battani says. “You'll want to know about the financial activity happening with patients even when they're not in your facility because it's about expanding services across a continuum of care, even from a financial perspective."
She adds that provider network management and contract management will determine ACO investment in applications and processes that will allow them to pay claims and to manage and distribute ACO revenues to all the participants in care delivery and patient service.
Read CSC Health Service's whitepaper "Health Information Requirements for Accountable Care."
Learn more about CSC Health Services.