The accountable care delivery model
By Charles W. Jarvis, FACHE, April 2011
Using technology to change provider and patient behaviors.
Charles W. Jarvis,
Healthcare delivery models are undergoing fundamental transformation, with collaborative-care programs emerging as an alternative to the current fee-for-service model. This evolution is driving medical providers to coordinate their care more effectively through a discipline known as the patient-centered medical home (PCMH), where each patient's care design has unique goals and health improvement targets known as health outcomes.
The concept of community-based collaborative care, dubbed an accountable care organization (ACO), and the PCMH are introduced in the HITECH section of the American Recovery and Reinvestment Act of 2009 (ARRA). In a broad sense, the PCMH, with its emphasis on placing patients at the nucleus of all care decisions, is actually a prelude to fully "accountable" care. The country indeed is poised to create more effective healthcare delivery if these care models can be implemented effectively.
However, fixing the suboptimal healthcare system currently in effect will require total reform of reimbursement policies and major reform of healthcare delivery mechanisms. Focus must be shifted from acute, episodic care to more preventive wellness care, with more patient responsibility and provider care coordination at the helm.
Achieving such a high degree of synchronization and accountability is dependent on the industry's ability to enable a more robust flow of health information. That is why the electronic health record (EHR) has become such a central component of these efforts. But the EHR alone, if used merely as an electronic version of the paper patient record, is not enough.
Transforming healthcare into an integrated, patient-centered and accountable care model requires that the EHR be used not just to automate data, but to fundamentally change provider and patient behaviors.
Paving the road ahead
Healthcare today is somewhat analogous to automobile travel prior to the development of the interstate highway system. People could move about on local roadways, but the process was not always terribly efficient. The path between two points often required a slow, circuitous route instead of a fast and straight one.
So it is with the healthcare delivery system today. Highly trained medical providers effectively care for patients and create accurate and complete patient records within healthcare organizations. They improve care locally in much the same way that the first automobiles traversed neighborhood roads slowly and carefully within communities. The introduction of the EHR in these care settings has made information flow even more effective, much like newer automobiles could travel faster and safer down neighborhood roads.
Truly accountable, patient-centered care starts with the ability to exchange standards-based data, allowing all patients and healthcare organizations to easily communicate with one another much like the first, disjointed interstate highway system allowed faster, safer automobiles to travel more quickly between two points. Two existing continuity-of-care standards — the continuity-of-care record (CCR) and the continuity-of-care document (CCD) — are steps in this direction. Hopefully, within a few years the industry will choose a single standard to embrace.
Standards will make it easier to link EHRs together, but EHRs still must be connected in ways that will allow the most useful flow of health information coordinated around the individual patient and community. This is where the health information exchange (HIE) plays a critical role. The combination of EHRs and HIEs will effectively move health data from point to point, and from the patient to the broader community. It will disseminate the population health information needed for accountable care to achieve its goal of a more effective healthcare delivery system.
Yet it is crucial not to overlook one important difference between roadways and healthcare: the inherent individuality of healthcare. While use of multiple EHR systems requires standards-based data interoperability, providers must go farther in order to fully maximize the efficiency of their delivery processes, enable complete collaboration and enhance patient care outcomes with measurable results. In other words, care models are important, but it is really the medical providers embracing these models and sharing the total care of the patient that will help us achieve the improved health outcomes.
Bridging the gap
Without EHRs and HIEs, it has been difficult for providers to develop genuinely collaborative communities of care. As a result, healthcare has grown essentially as a cottage industry, with individual providers using their own chosen methods to tend to their own unique patients.
It is this element of individuality that makes nationwide HIT interoperability more difficult to achieve than the interstate highway system. Indeed, the healthcare reform envisioned by the PCMH and ACO models requires much more than simple data interoperability; it requires a commitment to collective healthcare responsibility. "Accountability" is the operative word in collaborative care models, and it starts with patient and medical provider.
So how do we bridge the gap?
The first step involves the industry's willingness to pledge adherence to a uniform set of data standards. While standardization is not absolutely necessary — just as interstate highways are not absolutely necessary for automobile travel — it nevertheless is essential to building the greatest degree of efficiency into any model of care.
In addition to efficiency, standardization also allows independent third parties to offer compliance certification. Certification is a powerful tool to help organizations know whether a given EHR system provides the kind of standards-based data exchange necessary to achieve interoperability (the ability of disparate systems to talk to one another) in these collaborative care models. Once you connect certified EHRs under one HIE, you establish the beginning of information flow to create true, community-driven healthcare.
The next step is for providers to accept data about patient care that comes from another trusted medical provider in the community, which the original provider may not have had any part in developing. The third step is the compliant patient taking responsibility for his health. He must change his behaviors or maintain a discipline of living that allows him to play a major role in controlling his own healthcare outcomes.
Make no mistake: Leveraging technology to go beyond basic data interoperability and actually enhance patient care will not be easy. It requires everyone to make changes, from patient to provider, facility to payer.
In order to lower costs and improve the quality of care, the current focus on acute, episodic treatments must be replaced with community-directed, population-based therapy. Rather than simply reacting to individual illnesses as they present, providers must be encouraged to use data analysis and "best practices" to spur better preventive measures. Public health initiatives, wellness campaigns, patient education and even healthcare "peer pressure" must be employed to raise the standards of care. Three factors are integral to success:
1. Patients must be invested in, and take responsibility for, their own healthcare;
2. Care must be coordinated for maximum efficiency by those providers in the best position to engage in highly personal patient/provider relationships (e.g., primary care physicians); and
3. Reimbursement must be restructured in such a way that preventive care is rewarded rather than discouraged.
Overcoming the final factor — restructuring reimbursement methodologies — poses the most widely debated challenge with regard to bringing collaborative models of care to fruition. Yet it is only the penultimate challenge. The ultimate challenge is getting the patient to accept the consequences of his healthy or unhealthy lifestyle.
True healthcare reform and accountable care are much bigger and broader than the physician/patient relationship and the technology that comes with these care models. They entail a reform of society itself, bringing it to a point that applauds healthful choices instead of potentially harmful ones.
Sharing patient information between specialties within the healthcare community is the start of more integrated care. From there, sharing patient data among larger entities — geographic regions and payers, for instance — will help gather more accurate data for the formation of "best practices." This is how data uniformity begins to shape the meaningful use of HIT.
HIT then can begin to help providers work toward improving overall population outcomes, as opposed to solving episodic patient problems. Right now, for instance, a physician might measure how long it takes for patients to receive an appropriate prescription. But that is only a measurement of the healthcare process — it is not a measurement of patient outcomes.
Providers should be asking: "Is my patient healthier, happier and better off due to my interventions?" And patients should be asking: "Am I taking appropriate responsibility for my health and not relying on medicine to make up for my unhealthy behavior?" When the answers to both of those questions are yes, we will be well on the way to creating a healthier society and not one that simply consumes scarce healthcare resources.
Charles W. Jarvis is
VP of healthcare services and
government relations for
NextGen Healthcare Information Systems.
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