New population health tools needed to effectively manage ACOs.

H04_ACOs_Symphony_Ron Parton_90x121 H04_ACOs_Symphony_Subbu Ravi_90x121
         Ron Parton         Subbu Ravi

The Centers for Medicare & Medicaid Services’ (CMS) final rule on accountable care organizations (ACOs) includes 33 measures on overall performance while allowing providers options on shared savings. While the new ACO rule is likely to persuade payers and providers to provide better quality at a lesser cost, it now draws focus on a greater need for new population health information technology to support ACOs.

Current reporting technology and electronic health records (EHRs) may be able to provide basic reporting on the measures, but they are woefully inadequate at meeting the ACO requirements for improving care, enhancing the patient experience and reducing costs. Health information exchanges may provide continuity of care records for patients at the point of care, but they do not integrate care plans, document interventions, support task management or measure outcomes. New population and care management systems will be required to support primary care medical home models, care coordination, case management and transitions of care. Advanced healthcare delivery will require the adoption of new information systems and tools that:

  • Provide rapid, flexible and continuous performance reporting;
  • Promote the proactive identification and management of the “highest risk” patients;
  • Accurately attribute patients to physicians and care teams;
  • Allow care teams to coordinate care across the entire continuum and systematically manage multiple chronic illnesses through use of a common care plan – clinical integration;
  • Integrate information and workflows across EHRs, care teams, providers, community resources and health information exchanges (HIEs);
  • Support real-time decision making and population surveillance using evidence-based guidelines;
  • Engage, educate and support patients in self-care, prescription drug adherence, lifestyle improvement and prevention; and
  • Aggregate and manage data from multiple disparate data sources (clinical, administrative and financial) with reliable master patient index functionality.

Data warehouse/data repository
It is important to be able to integrate multiple data sources, including ambulatory and inpatient EHRs, labs, scheduling, billing, health information exchanges (HIEs), insurance claims, remote monitoring, patient self-reports, research, demographic, administrative and financial data.

In general, the data warehouses that are included with EHRs are not designed for integrating financial, clinical, research and administrative data from multiple external sources or for use in tracking healthcare interventions and outcomes for populations. To improve and report on performance, an ACO will need to create a data warehouse and/or repository to store all available data on its patients and services and make this data available across the enterprise to support population and care management initiatives.

Population health and care management system
A population health and care management system should include an enterprise multi-disease registry with measures and reporting; workflow support and tools for case management and health coaching; care team performance tracking with an embedded rules engine to support follow-up tasks and reminders; and creation and sharing of care plans that include longitudinal care views of goals and progress.

Chronic illness registry tools typically have been developed for single diseases and have produced lists of patients that need follow up or have “care gaps,” but do not include case management tools or health coaching functionality to manage and/or document the work in coordinating care and assisting patients with their illnesses. These tools help facilitate identification and can report the results, but they do not manage the workflow across multiple diseases or support case management/health coaching. New population health and care management systems are now available that are multi-disease and can help care teams with role-based task management, care coordination, prescription drug adherence, patient letters and reminders, lifestyle tracking to goals and comprehensive clinical and financial performance reporting. They are designed to be flexible and accommodate different workflows across the care teams and also allow for ongoing changes in measures, definitions and guidelines as required.

Population surveillance rules engine
Staff should be able to monitor care processes and outcomes using evidence-based guidelines, with links to both a population and care management system and the EHR.

Most EHRs will facilitate reminders that “pop up” during a patient encounter to flag the need for routine preventive screenings, immunizations, lab tests and care gaps, but they are not very flexible and do not connect to a follow-up tracking system that facilitates role-based workflow for the care team.  Since EHRs are visit based, they generally don’t trigger actions between encounters, don’t allow flexible workflows for follow up across the care teams and don’t document interventions or communication attempts. Evidence-based rules engines that exist outside of the EHR can support population management by the care teams for actions that are triggered, often avoiding the expense of a face-to-face visit with the practitioner. New population health and care management systems will incorporate evidence-based rules engines for population surveillance and support care teams in closing the care gaps.

Clinical integration of systems
Integrating population health IT with EHR functionality and workflow is a must.

The complete set of information about each patient must still be stored in the EHR to support optimal patient care. This requires that new information generated in a population and care management system be fed back to the EHR, so it is available at the point of care for decision making and follow up. The workflow between the EHR and the population and care management system must be optimally integrated to help assure efficiency and access to the data. Over time, some of the population health functionality that isn’t available now may be incorporated in the EHR itself. However, EHRs are usually structured around encounters rather than populations, care teams, or non-encounter-based workflows. This may ultimately limit the capacity of most current EHRs to incorporate population health IT functionality. Certification Commission for Healthcare Information Technology (CCHIT) certification ensures that the EHRs are positioned to exchange patient information bi-directionally. Little attention has been given to developing functional integration of workflows across systems, access to computer physician order entry (CPOE) for population management or making this integration commonplace..

Analytic tools
Analytics tools should focus on predictive modeling, episode grouping, severity and case mix adjustments.

Predictive modeling tools support proactive identification and stratification of the highest-risk patients for potential referral to complex case management. A parallel methodology is also needed to measure cost and utilization with case mix adjustment, typically through episode groupers.

Remote monitoring technologies
Home monitoring must interface with care management and EHRs.

High-risk patients with certain chronic illnesses such as congestive heart failure, diabetes, hypertension and chronic obstructive pulmonary disease may benefit from utilizing home-monitoring devices that allow them to track their own illnesses and work interactively with a case manager and/or health coach who can also follow and track their outcomes in real time. This information can be sent back to both the population and care management systems and the EHRs.


Patient and family engagement technologies
Patient and family engagement technologies include Web-based portals linked to personal health records; lifestyle tracking tools; handheld technologies for education, tracking, reminders and interactive learning; Web-video technologies for virtual provider visits, health coaching and case management; and interactive assessments, questionnaires and connectivity to measure patient outcomes and provide feedback on patient experience.

Patients are now being provided access to their own medical record information and encouraged to learn more about and manage their own health risk factors and chronic illnesses. Mobile and tablet technologies, Web-based patient portals and Web-video technologies are allowing patients to have better access to their care teams, medical knowledge and tools that help them to improve their lifestyles and achieve better results in managing their illnesses. These technologies can be linked to both their population and care management tools and their EHRs. Patient experience questionnaires, interactive assessments for depression screening, assessment of activities of daily living, pain management follow up, etc., can be administered using email, patient portals and/or handheld technologies.

Population health information technology
Population health information technology is complex to implement but critical for ACO performance.

All the pioneering organizations participating in the Medicare Physician Group Practice demonstration, such as Marshfield Clinic, have significantly redesigned care workflows and introduced population health information technology that makes clinical data more readily available to the practitioners and care teams, including “add-on” disease registries or embedded tools within their EHRs. It may be disappointing that after having spent significant amounts of time, effort and money to implement electronic medical records, there is more work ahead in assimilating a complete set of population health information technologies to become a successful ACO. The consolation is that none of these pioneering organizations have used all of the population health and care management tools that are now available and yet most of them accomplished positive results. One of the keys going forward will be to prioritize the functions that are most likely to achieve results and implement those first. See chart for a matrix of population health IT and functionalities.   

About the authors
Ron Parton, M.D., is chief medical officer, and Subbu Ravi is vice president of solutions, Symphony Corporation. For more on Symphony Corporation, click here.

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