hmt-201201-acos-hayes-shefali_90x126Interoperability standards could be a prerequisite to measuring care.

As part of healthcare reform, accountable care organizations (ACOs) are a growing foundation for the future of healthcare. However, what will exist within that foundation? Health information exchanges (HIEs) may be one component. So, what makes one think of data sharing as important? Beginning this year, providers became eligible for federal funding to help them meet benchmarks called meaningful use (MU) standards. Data sharing is an important part of the MU standards. MU criteria could allow an ACO to perform effectively by way of improving outcomes, managing population health and delivering personalized medicine.  Also, the perception is that HIEs will facilitate meaningful use and enable health plans to interact directly with providers at the time of care and to provide automated alerts, reminders and other guidance based on population health data.   

Interoperability standards could be a prerequisite to measuring care. Interoperability standards define the vocabulary, protocols and presentation features of healthcare information in order to achieve interoperability between systems. One thing to note here is that the definition of “interoperability” varies by organization. Several standards bodies are in the process of developing or may have developed interoperability standards for various types of information. Some of the latency in the general adoption of standardized communication has been due to the various competing standards developed by different standards bodies. There has been an increasing amount of work to build bridges between the standards (translations). This is being done so that healthcare messages/documents created in one standard can be translated into another without the loss of information integrity. For example, Health Level Seven International (HL7) is a global authority on standards for interoperability of health information technology with members in over 55 countries.

Listed below is an example of HL7’s V2 Messaging standard:

HL7’s Version 2.x messaging standard is the workhorse of electronic data exchange in the clinical domain and arguably the most widely implemented standard for healthcare in the world. There have been seven releases of the Version 2.x standard to date.  The HL7 standard covers messages that exchange information in the general areas of:

•    Patient demographics;
•    Patient charges and accounting;
•    Patient insurance and guarantor;
•    Clinical observations;
•    Encounters including registration, admission, discharge and transfer;
•    Orders for clinical service (tests, procedures, pharmacy, dietary and supplies);
•    Observation reporting, including test results;
•    The synchronization of master files between systems;
•    Medical records document management;
•    Scheduling of patient appointments and resources;
•    Patient referrals, specifically messages for primary care referral; and
•    Patient care and problem-oriented records.

Interoperability standards could be a fundamental component within an ACO model. Hence, is it essential to have payer interoperability and data sharing integrated in an ACO model? Simply put, yes. As a result of the clinical encounter, clinical and business processes incur many data cycles that bear opportunities for cost savings and improved quality of care.  

Listed below are eight reasons why it is essential to have payer interoperability and data sharing in an ACO model:

1.    Importance of payer role;
2.    Member’s health lifecycle;
3.    Standardization of billing and claims operations/management;
4.    Clinical decision support;
5.    Enhanced eligibility;
6.    Cost savings;
7.    Developing a sustainable model of an HIE; and
8.    HIE-to-HIE collaboration and connectivity.

Payer role

One of the key external partnerships an ACO may have is with the payers. The relationship between the payer and provider has evolved. The relationships are transforming the payment and delivery care processes. The payers may require the ACO to sign participation agreements. It is hard to say if providers and health plans will become collaborators on ACOs. However, one thing is very clear: Insurance companies’ new interest in health IT services will have a vital impact on ACOs. Health plans are beginning to purchase software vendors that can make HIEs happen, as Aetna purchased Medicity and United acquired Axolotl. Insurance company staff can have the skills and history to deal with risk management, population management and actuarial risk balancing. For example, network officials could scan the clinical data and make personal phone calls to primary-care doctors if they haven’t been seeing patients who have high acute-care utilization. The data is also useful in making sure that discharged patients receive necessary follow-up care, and in helping the executives quantify the results of their efforts in metrics, such as reduced readmission rates. Could one surmise that it is time for a fee schedule or payment methodology that payers, providers and patients could agree on that would pay for better quality of care, managing patient populations and productivity?

Member’s health lifecycle

One of the major challenges a provider may experience is not having the complete picture of a patient’s health due to lack of information. Continuity-of-care information that is shared in a timely manner among the patient-care team and enabling care coordination across multiple providers is thus essential for meeting the requirements and workflow of the ACO. An ACO’s success in part may hinge on its ability to share patient data at the point of care and rely on historical and longitudinal data for use in managing population health. Families may move from payer to payer or provider to provider in their lifetime. Being able to see a longitudinal view of the patient’s health record and the patient’s claims record could provide ACO-participating clinicians invaluable information. They could effectively treat the patient’s condition, even if a provider, such as a specialist, is given only a portion of that patient’s overall treatment plan or health record. Likewise, payers may need to access records of recent or past procedures processed through another payer for a newly insured life. Whatever the degree of financial risk in particular ACO contracts, many of them may require providers to use a population health management (PHM) approach. Hence, it would behoove the ACO to review patients who use healthcare services and those who do not use healthcare services. The prevalence of disease in a patient population may be great because patients may go undiagnosed or may have fallen off the provider’s radar screens. In addition, patients with known conditions may be at risk of developing complications because of healthcare gaps and/or lack of compliance. To do PHM effectively, ACOs could turn to automation tools that not only extend the functionality of their electronic health records (EHRs) but also reduce the burden of routine care-management work on their clinicians.

Standardization of billing and claims operations/management

Payer interoperability and data sharing within billing and claims operations/management consist of standards. The Accredited Standards Committee X12 (ASC X12) is a standards development organization that develops standards for electronic information exchange. Such standards could be those of HIPAA transactions as indicated below:

Between  providers and payers:

•   ASC X12 278 Patient referrals;
•   ASC X12 837 Claims submission;
•   ASC X12 276 Claims status/inquiry;
•   ASC X12 277 Claims status/inquiry response;              
•   ASC X12 835 Claims payment.

Between health insurers and health purchasers:

•   ASC X12 834 Membership enrollment;
•   ASC X12 820 Premium payments; and
•   ASC X12 837 Coordination of benefits.

Each of these transactions facilitates payer interoperability and aids in data capture and data sharing.  

Aside from the ASC X12 standards, another initiative will impact payer interoperability and data capture. This initiative is the ICD-10 implementation. The standard electronic health record (EHR) and health information exchange, being championed by the federal government and the industry, rely on the use of terminology systems for the collection and storage of data. Classification systems, such as ICD-10, have been built to convert the data in these terminology systems to secondary data for a variety of uses. Furthermore, the ICD-10 initiative could allow for more descriptive and better-categorized ICD-10 codes, which can enable diagnosis classifications that more completely represent the severity of medical conditions. Payer functions, such as research, reporting and actuarial, will need to develop ways to compare historical ICD-9 data to ICD-10 data. This comparison can pose a challenge, as the mapping between the new and old codes is not always one to one. There may be many ICD-10 codes that map to one ICD-9 code and vice versa and ICD-9 codes that do not map to ICD-10 codes. Once the comparison is completed, payers and ACOs could begin to build databases housing population health data. However, standards on the clinical side are evolving with the creation of the Nationwide Health Information Network (NHIN) CONNECT and Direct projects.

Enhanced eligibility

Furthermore, the HIPAA transactions ASC X12 270 and ASC X12 271 can be used for checking eligibility and benefits of a patient. Often times, providers check for eligibility or pre-authorizations for higher risk or higher cost procedures. However, ACOs could look at providing these checks for all types of patients to help determine the best treatment options. An ACO could provide more knowledge of prior patient treatments across multiple providers, best practices and outcomes. ACOs could help the provider reduce unnecessary or redundant treatments, resulting in cost savings for payers and cash-flow improvements for providers.

Clinical decision support

The information from checking eligibility and data sharing could simplify clinical decision support. For example, a primary-care physician could look at this type of data and make inferences as to when a patient had an annual physical in the last 12 months and send a reminder. An ACO may focus on quality measurement and management, including internal and external reporting, typically using quality measures largely dictated by the payer. In many cases, these measures derive from evidence-based medicine and may correlate to clinical decision-support tools that enable higher standards of measurement, evaluation and adjustment of practices. ACOs will also need revenue cycle software that can manage new payment models, such as bundled and capitated payments, and that can help distribute shared savings. In some cases, ACOs may need payer data and analyses of linked payer/ACO data, including estimates of projected costs and other metrics for the ACO’s patient population. ACOs will need the ability to exchange data within the ACO and across providers (for example, hospitals, medical practices and post acute-care providers). This requirement involves standards-based internal interoperability and internal and external use of standards-based health information exchange (HIE).

Sustainable HIE model

An HIE that has the capability of storing clinical registries and encourages the use of e-prescribing could be well suited to assist ACOs in gathering data, which is a requirement for reimbursement and associated bonuses based on outcomes. HIEs and their anticipated analytics may drive the need for a more conclusive solution that is vendor neutral and patient-centric. The rapidly evolving technology and the inability of organizations to scale up with staff, facilities and infrastructure may suggest that cloud delivery models create a way for enabling technology adoption at a lower cost, risk and shortest time to go-live. One of the keys to success will be using strategic archiving and cloud services to provide the infrastructure behind the emerging data use and sharing models that are being driven by meaningful use and ACOs.

One approach to building the ACO infrastructure is to replace existing systems in favor of a single information system. A practical and cost-effective path may be to adopt HIE technology that enables ACO participants to leverage existing information systems to exchange data across care locations, facilitate care collaboration, perform quality reporting and ensure all data for fulfilling ACO objectives is captured.

Some payers have created claims-based health records for their patients and have made these available to providers via web-based system interfaces. These claims-based health records could provide details on care interactions for a patient and potentially be interfaced within the ACO to provide greater details – on prescriptions, treatments, surgeries, immunizations, etc. – to create a more complete longitudinal patient record.

HIE-to-HIE collaboration and connectivity

An ACO, a hospital HIE, a regional/state HIE, a payer or a federal agency are all data sources with different policies and procedures. Each of these may interact with each other in the data-exchange ecosystem. In many instances, the role of a HIE is be a conduit for data and not the end point for data. Small providers and organizations may start with simple basic information-exchange requirements, perhaps through the Direct Exchange Project, to satisfy various meaningful-use standards. The Direct Project seeks to replace slow, inconvenient and expensive methods of exchange (such as paper or fax) and provide a future path to interoperability. Large organizations and state HIEs may require nationwide information exchange, including information exchange with payers and/or federal agencies, such as The Centers for Medicare and Medicaid Services (CMS). This could be achieved through NHIN CONNECT, an open-source software solution that enables health information exchange – both locally and at the national level. CON
NECT employs Nationwide Health Information Network standards and services to ensure that health information exchanges are compatible with other exchanges throughout the country. Furthermore, to enable connectivity between many kinds of health ecosystems, considerations could include:

•    Full-audit ability and compliance with HIPAA and other federal regulations;
•    The ability to deal with state laws that may change as data crosses state lines;
•    Non-repudiation of clinical data;
•    The issuing of certificates and management of trust through identity brokers;
•    The ability to accommodate different models for patient consent, opt-in and opt-out; and
•    The discoverability of data and responsibility for accounting of disclosures.

In addition, some of the interoperability benefits for payers could be:

•    Standardized content to facilitate the exchange of eligibility and enrollment information among payers;
•    Innovative solutions for transporting eligibility and enrollment data:
?  Point to point: Small providers and organizations can reuse direct backbone for simplified eligibility and enrollment transactions;
?   Reuse of existing systems: Modular approach to support vendors who want to add this as a feature through CONNECT;
•    Increased access to care through expedited eligibility and enrollment by standardized and efficient information exchange:
?  Providers rightfully fear providing care to someone who cannot pay;
?   Real-time access for providers to determine, “Can you pay?”

ACOs may, in fact, be the model that could finally cause the financial need for clinical data exchange that has eluded healthcare delivery for decades. The key to its success, however, will be patient-centered HIE technology that enables true communication at critical handoffs, collaboration across the continuum of care and analytics to determine best practices to reduce costs while improving quality.

Cost savings

ACOs must deliver significant cost savings by reducing inefficiencies in healthcare delivery and payment processes. HIE solutions offered through various companies may serve that goal by automating delivery of patient records, referrals, orders, prescriptions and refills, test results and diagnostic imaging. The savings in physician and staff time and other cost factors are significant and greater when billing systems are integrated.


It makes strategic and business sense for payers and providers to collaborate on how to take substantial cost out of the healthcare delivery system. Acting independently, neither medical groups, hospitals nor health plans have the optimal mix of resources and incentives to significantly reduce costs.

Payers have core assets such as marketing, claims data, claims processing, reimbursement systems and capital. It would be cost prohibitive for all but the largest providers to develop these capabilities in order to compete directly with insurers. Likewise, medical groups and hospitals are positioned to foster financial interdependence among providers and coordinate the continuum of patient illnesses and care settings.

Payers and providers should commit to reasonable clinical and cost goals, and share resources to minimize expenses and financial risks. It is in the interest of payers to work closely with providers on risk-management strategies because insurers need synergy with ACOs to remain cost competitive. It is in the interest of ACOs to work collaboratively with payers early on to develop reasonable and effective performance benchmarks. Hence, it is essential to have payer interoperability and data sharing integrated in an
ACO model.              

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