July 16, 2013
7 Portals Powering Patient Engagement(click image for larger view and for slideshow)
Information technology is indispensable to the success of an accountable care organization. You can't have coordinated healthcare without the IT to back it up, and with nine of 32 pilot ACOs dropping out of the program, industry leaders are assessing what it takes to do ACOs right and what lessons they've learned so far.
The Centers for Medicare and Medicaid Services said Tuesday that nine of the 32 pioneer ACOs were dropping out, and two of the ACOs shared losses totaling approximately $4 million. ACOs are one of the big ideas of U.S. healthcare reform -- that by paying providers to keep people healthy, rather than for the number of procedures they do, care will improve and costs will fall.
At this critical juncture of the ACO program, we spoke with technology leaders at three pioneer ACOs that plan to stay in the program. These leaders highlighted three key areas where information technology provides a foundation for successful ACO operation.
At the core of information exchange is the adoption of an electronic health record system. If implemented to allow data sharing, EHRs allow multiple doctors to manage patient care from exam room to hospital bed to the patient's home.
Atrius Health uses Epic's EHR system at multiple levels. In the exam room, the system is used to document the patient visit, order medication or laboratory work, and check if preventative care is up-to-date. The system also provides "decision support" information that helps physicians manage care to make it well-coordinated and less costly, said Richard Lopez, the chief medical officer at Atrius Health. Decision support can give physicians the option of generic medication over brand medication, and will display the costs of certain labs.
"We do this not so much to impact what the clinician is going to do, but to sensitize clinicians to the cost of services provided," Lopez said.
Atrius also uses Epic to facilitate communication between primary care physicians and specialists as well between Atrius's preferred hospitals.
Patient engagement, an increasingly hot topic in healthcare IT, plays a role in ACO information exchange as well. Patient engagement is about improving care but it's also a smart business move, said Bill Spooner, CIO at Sharp Healthcare.
"We want our patients to be sticky," he said.
In other words, Spooner wants patients to come back to Sharp for their care. Sharp does this by creating a substantial online presence and patient portal. Atrius and Beth Israel Deaconess Medical Center in Boston also have patient portals where patients can view upcoming appointments and test results, among other personal information.
Information exchange has boundaries, at the policy level and the technical level. The diversity of privacy laws in the U.S. makes the creation of a uniform national EHR system challenging, said John Halamka, CIO at BIDMC. Interoperability of different vendors' EHR systems is also a challenge, as "there aren't uniform standards for these systems to talk to each other," Lopez said.
Adoption of new technologies is also challenging. Just because an ACO has adopted an EHR system doesn't mean it's being used effectively, Spooner said.
"There is clearly some loss of productivity in the early days of learning EHR, and the question is how to get through that as quickly as possible," he said.
Atrius's Lopez said there are varying degrees of clinician competence with these new systems.
"Some physicians feel it slows them down, and that it's a little clumsy," he said. "There's a continuous effort to get clinicians to be proficient with the technology so that using this fantastic tool doesn't slow them down."
Once a provider collects and aggregates patient information, it needs to analyze the data in order to identify gaps in patient care, Halamka said. Many ACOs have created data warehouses for clinical information, and they're using those to analyze and assess patient wellness.
Part of the assessment includes patient rosters used for population health management, which provides primary care providers, population managers and care managers with a holistic look at all of a system's chronic-care patients, Lopez said. These rosters can identify gaps in care by spotting people with certain conditions who are in need of preventative care measures or by identifying those whose test results are abnormal.
For example, a doctor would be notified if a patient with asthma didn't receive a flu shot, and the care manager would take action to get that patient vaccinated, instead of treating the patient after he or she was already infected.
There is also a high-risk Medicare roster that identifies patients with a high risk of being readmitted. Doctors can then take steps to prevent re-admittance.
Quality metrics are also taken from the data, Lopez said. These metrics are part of the calculation of how one gets paid for the care of patients.
A major challenge in data analysis has been standardizing medical terminology, Halamka said. One doctor might diagnose a patient with hypertension, another doctor might call it high blood pressure and another might call it elevated blood pressure. The solution is mapping. BIDC combatted this problem with Massachusetts eHealth Collaborative, a nonprofit company that takes data from multiple systems and maps common terms to enter them into the database in a standard form.
Once the information and analytics pieces are in place, providers still must take the right actions to deliver quality care, Halamka said. Often that requires changes to the processes within the management of a practice. BIDMC, for example, places "pod leaders" within each practice who are responsible for disseminating data on performance to doctors and holding them accountable for quality and costs.
"You must have a foundation of IT in order to manage risk," Halamka said. "It is impossible to use standard tools that were great in a fee-for-serving world in an accountable care world that requires continuous management of wellness."
Key challenges looking forward will be managing risk and keeping the ACO model viable, especially considering the mixed reviews of Tuesday's CMS report. CMS reported that all the ACOs proved adept at improving care quality, but many couldn't deliver the sought-after cost savings.
Better IT systems for managing and analyzing patient data will be one element of lowering costs. For example, all 32 pioneer ACOs met their quality reporting requirements, but "we also know that simply reporting these measures took too much time and resources, and that Pioneers and MSSP ACOs need better solutions for handling the administrative side of these contracts," said The Advisory Board's Tom Cassels, in a Q&A on the consultancy's site.
Another survival element for ACOs goes back to those patient engagement systems, and whether ACOs provide an experience that keeps customers happy.
"The interesting thing about the current state of ACOs is that we call them accountable care, but the only person that is accountable is the provider," Spooner said. "The patient has the option to go to any provider they want, yet the provider is accountable for the care and the cost. We need to do our best to make sure the patients come back."
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