Emerging Care Models Require a New Approach to Interoperability, Information Exchange
From accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) to the Comprehensive Primary Care (CPC) initiative, emerging care models have upped the ante in terms of interoperability and information exchange. In particular, the need to better manage risk through improved care coordination and utilization management requires the ability to continuously track key quality and performance metrics and share information across a patient’s continuum of care.
The critical need to link primary care physicians, specialists and other providers to comprehensive patient data in real time is best exemplified by two recent reform efforts announced by the Centers for Medicare and Medicaid Services (CMS), the ACO program and the CPC initiative. Both encourage collaboration of care to increase quality and reduce costs by tying reimbursements and financial incentives directly to quality and performance measures. And both present significant challenges when participating providers lack the ability to collect, analyze and exchange actionable data.
Measuring Quality, Influencing Outcomes
The ACO program for Medicare teams providers and hospitals into plan-like entities operating in the fee-for-service (FFS) system. Though CMS ultimately bowed to heavy criticism and reduced the number of quality measures ACOs must track from 65 to 33, the agency clearly is emphasizing the importance of quality.
Thus, all entities must ensure they can drive better outcomes if they are to succeed in the program. Doing so requires ACOs to make the right personnel and infrastructure investments to share data and forge team-based care planning and quality improvement.
The CPC initiative, which is most analogous to a PCMH program, encourages primary care physicians to proactively assess patients to determine their chronic care and preventive health needs and provide appropriate and timely care. This includes identifying high-risk individuals through risk stratification and provider intervention through case, care and disease management. The program also seeks to improve care coordination, enhance patient and caregiver engagement and encourage availability of and access to relevant patient information at all times.
On the upside, the CPC initiative, which is initially focused on Medicare, appears to be more flexible and less administratively burdensome than ACO programs. While CMS alludes to using up to 25 quality and other measures to assess outcomes of the program, the agency also says that the measures are likely to be a subset of the ACO measures. Savings will be determined at the market level. To prevent participating providers from gaming the system, actual payouts will be based on quality indicators at the practice level.
If the FFS system is to remain, focusing on incentives for primary care providers to case-manage and provide comprehensive care is the best way to root out waste and inefficiency and promote better outcomes. This is why the CPC initiative could mean a sea change for Medicare over time.
Integrated, Interoperable Information Sharing
ACOs, PCMHs and the CPC initiative all require a way for physicians to easily, affordably and efficiently collect, share and manage significant volumes of data from multiple disparate sources. A major component is the ability to monitor key performance metrics and share information across a patient’s continuum of care so that care gaps trigger interventions before quality is impacted. By sharing actionable information, providers are able to influence outcomes and quality scores, which is essential to success when reimbursements and financial incentives are linked to quality and performance.
It is here that the evolution of an integrated care management, quality and compliance platform that leverages the flexibility of the cloud holds a great deal of promise. It enables the linking of all participants — from primary care physicians and specialists to case managers and home health providers — in an ACO or PCMH to patient information in a way that is meaningful to their individual needs. It also lowers the barriers to innovation and modernization of health IT systems by minimizing costs, increasing scalability and improving accessibility and security. Finally, it enables integration of workflow processes beyond the four walls of an entity and improves interoperability by utilizing open standards.
In particular, initiatives should deploy an integrated software platform that drives improvements in care, quality and compliance by addressing seven key considerations:
1. The ability to receive enrollment, eligibility and demographic data on assigned beneficiaries, as well as claims data, ensuring access to a comprehensive clinical history for each patient
2. Predictive modeling and stratification tools to identify high-risk or multiple comorbid cases in need of intervention
3. Tools to identify Healthcare Effectiveness Data and Information Set (HEDIS) and other care gaps
4. Proactive identification of those in need of preventive care and chronic care management
5. Tools that streamline comprehensive case and disease management, including assessments, care plan creation, and monitoring/fulfilling care plan tasks and interventions
6. Comprehensive medication reconciliation and drug monitoring capabilities
7. Integration with any existing provider and member portals
Because they are on the cloud, integrated care management, quality and compliance platforms also provide a high level of flexibility so that initiatives can configure everything from user access to business intelligence tools to meet their unique organizational and patient population needs. This kind of flexibility also allows for rapid deployment and quick response to regulatory and market changes.
Finally, these integrated platforms eliminate interoperability issues by facilitating real-time information sharing without requiring participating organizations to replace existing legacy systems. This means initial capital requirements are minimal and total cost of ownership is low, resulting in a rapid return on investment.
Achieving Multiple Objectives
Three things happen when an integrated care management, quality and compliance platform is deployed via the cloud within any of these emerging care and reimbursement models. First, the dual barriers of a steep initial capital investment and total cost of ownership are removed, so true innovation and modernization of health IT systems can begin. Second, physicians and other providers have access to the information they need to better manage their patient population and provide the detailed performance measures necessary to demonstrate the quality and outcomes that will dictate any shared savings. Third, patients benefit from improved coordination of care and better health management.
Going forward, a major component of a successful ACO, PCMH or CPC initiative will be the ability to share information within the organization and across the patient’s care continuum in order to improve clinical outcomes, track quality metrics and achieve shared-savings benchmarks. An integrated cloud-based platform provides a solid foundation to accomplish these objectives.
Anil Kottoor is the CEO and president of MedHOK (www.medhok.com), a leading provider of innovative modular software that leverages the cloud to enable organizations to meet quality, care and compliance objectives across healthcare business lines. He can be reached at firstname.lastname@example.org.